Every finding on record at Avir at Bryan

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to ensure stored foods in the 3-door reach in refrigerator located in the kitchen was labeled and dated to include the use by date or prepared/ pulled date. 2. The facility failed to ensure foods were stored in a manner as to prevent contamination (sealed). 3. The facility failed to ensure bread in the dry storage area was sealed in a manner to prevent contamination. 4. The facility failed to ensure dietary staff maintained a sanitary environment (scoops left inside dry storage container of sugar, soiled dry storage container tops, soiled interior of the reach in refrigerator). These failures could place residents at risk for food borne illness and cross-contamination.The findings include: During an initial tour of the kitchen on 05/30/26 at 12:11 PM revealed the following:In the (3-door) reach in refrigerator revealed a stainless-steel steam table pan which contained lettuce had a sheet of clear plastic wrap very loosely covering the lettuce and halfway falling into the lettuce exposing the contents to open air. An additional clear bag of lettuce was observed wrapped in plastic wrap with no pull date (removed from original manufacturer bag or best by date. A large frozen ham was observed on the bottom wire shelf defrosting and not on a drip-proof container; it did not contain a pull date for defrosting. The bottom of the refrigerator contained a tray with a white milky spilled substance that covered part of the tray and the bottom of the refrigerator.In the dry storage room revealed a shelf of bread which contained a clear bag of hamburger buns; the bag appeared with a baseball-size hole which exposed the bread to open air and contamination. A shelf was observed with 4 dry storage bins with blue lids; one contained sugar and was observed to have the plastic scoop left inside buried in the sugar. The bins were observed soiled on top with white powder/ residue. During an interview on 05/30/26 at 02:21 PM with CK A, she stated it was the facility expectation that items stored in the refrigerator were labeled and dated. She stated items should contain a date when the item were pulled out of its manufacturer bag or container or date prepared and the use by or best by date. She stated they had dated located on the refrigerator that told staff which dates to use and it was usually 3 days after it was pulled out of the original packaging or prepared. She stated if something was not labeled with a pulled date or use by date, they would not know potentially what the items were or how long it was sitting there and stated it could have gone bad; it could result in food poisoning and bacteria. CK A stated the lettuce mix in the metal container should have been completely sealed. She stated not sealing food completely had the potential to result in stuff falling in and cross contamination. CK A stated it was the expectation that scoops were not left in the containers in dry storage. She stated leaving the scoops inside in the food could result in cross contamination. CK A stated it was the expectation that cleaning occurred daily and as needed, she stated the dry storage bins should have been cleaned and the refrigerator should be clean and free of soiled items. She stated an unclean soiled area of the kitchen had the potential to attract pests, could be a hazard to employees, and could result in cross contamination. During an interview on 05/30/26 at 02:40 PM with the DM, she stated it was her expectation that items in the refrigerator were labeled with the prepared date if it was prepared in the kitchen or pulled and the use by date which she stated would be 3 days after being prepared. She stated a negative outcome of not labeling or dating food would be staff would not know when it was put there, they [residents] would not get quality food. The DM stated it was her expectation food stored in the kitchen was sealed in an airtight container if in the refrigerator to prevent things from dripping in it causing bacteria; dry storage bread bags should be tied/ closed and not exposed to air. She stated if bread was left exposed it could get dry or attract pests. She stated dry storage scoops should not be left in the containers but they should be placed in a bag, hanging, and labeled which indicated what the scoop was used for. She stated leaving the scoop inside the bins resulted in contamination. The DM stated all kitchen areas which included the refrigerators, freezers, floors, and bins should be cleaned after every meal service and maintained clean. She stated soiled kitchen surfaces attracted pests when not clean. The DM stated the pictures obtained showing the items described did not meet her expectations. During an interview on 05/30/26 at 04:07 PM with the ADM, he stated it was his expectation the dietary staff followed policy in that items stored in the refrigerator should be labeled and dated and it varied based on what it was. He stated items should have an open date and they also needed to have a use by date. He stated salad/lettuce mix should be covered/ sealed and should have a use by date. He stated the scoops for the dry storage should not be in the containers but should be in their own storage bags and hanging. He stated dry storage bread should be stored on a shelf with the received date and use by date, he stated the bread should be sealed. He stated the bag would need to be covered or in a new bag if ripped. The ADM stated a potential negative outcome of not labeling or dating would be staff could serve food outside of food safety standards. If food was exposed and made to the residents, he stated it could be an infection control issue due to pathogens. The ADM stated the kitchen should be cleaned daily and as needed after each meal, a negative outcome of the kitchen not being cleaned could be an unsanitary environment that could cause health concerns, he stated he was not clinical and did not know specifically but knew it could cause people to be sick. Record review of the facility's Food Receiving and Storage policy, revised November 2022, reflected:Foods shall be received and stored in a manner that complies with safe food handling practices.Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.Dry Food StorageNon-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean.Refrigerated/Frozen StorageAll foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Record review of the facility Food Preparation and Service policy, revised November 2022, reflected:Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe foodhandling practices.Appropriate measures are used to prevent cross-contamination. These include:a. storing raw meat separately and in drip-proof containers, and in a manner that prevents cross contaminationfrom other foods in the refrigerator;cleaning and sanitizing work surfaces Thawing Frozen Food1. Foods are not thawed at room temperature. Appropriate thawing procedures include:a. thawing in the refrigerator in a drip-proof container Record review of the facility's Sanitation policy, revised November 2022, reflected:The food service area is maintained in a clean and sanitary manner.All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Record review of the 2022 U.S. Food and Drug Administration Food Code revealed:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: P if(1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Of and(2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition.(A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it:(2) Is in a container or PACKAGE that does not bear a date or day; or3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.FOOD shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings.

Based on observation, interview, and record review, the facility failed to make sure that drugs are stored in locked compartments and only authorized persons have access for 3 of 9 medication carts (MC #1, MC #2, and MC #3) reviewed for drug storage and labeling.The facility failed to ensure MC #1, MC #2 and MC #3 were locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:Observation of the initial walk through of the facility on 05/12/2026 at 5:54a.m., revealed the ADON left MC #1 and MC #2 unlocked and unattended. Observation of the initial walk through of the facility on 05/12/2026 at 6:01a.m., revealed RN H left MC #3 unlocked and unattended. During an interview with the ADON on 05/12/2026 at 6:03a.m., she said she had been trained on medication storage. She said the policy for the medication carts was the carts were to be always locked. She said the person on the medication cart was responsible for locking the medication cart. She said if the medication cart was left unlocked and unattended a resident could get the medication; medication could come up missing. She said all staff monitored to ensure the medication carts were locked. She said staff monitored through observation. She said she left the medication cart unlocked because she got distracted. During an interview with RN H on 05/12/2026 at 6:16a.m., she said she had been trained on resident rights. She said the policy for the medication carts was any time staff walked away from the cart it should be locked. She said the nurse was responsible for locking the medication cart. She said if the medication cart was left unlocked and unattended a resident could access the medication and ingest the medications and cause harm, or medications could be stolen. She said the ADON and DON monitored to ensure staff were locking the medication carts. She said the ADON and DON monitored through observation. She said she was running around and she said she had a lot of things going on at one time and she forgot to lock the medication carts. During an interview with the DON on 05/14/2026 at 10:10a.m., she said she had been trained on medication storage. She said the policy for medication carts was that the carts should always be locked. She said the nurses were responsible for locking the medication carts. She said if the medication cart was left unlocked and unattended a resident or visitor could get into the cart and take medication. She said the DON monitored to ensure the carts were locked. She said the DON monitored through observation. She said she did not know why the ADON and RN H left the medication carts unlocked and unattended. During an interview with the ADM on 05/14/2026 at 11:38a.m, he said he had been trained on medication storage. He said the policy for the medication carts was that the cart was to be locked when the nurses were not working on the carts. He said the nurse primarily was responsible for ensuring the medication cart was locked, but anyone walking by the cart should lock the cart if it was unlocked. He said if the medication cart was left unlocked and unattended it could cause drug diversion; missing medication and the residents could rummage through the carts. He said the nurse manager, the ADM and DON monitored to ensure the medication carts were locked. He said the nurse manager, ADM and DON monitored by doing routine rounds and spot checks. He said he did not know why the ADON and RN H left the medication carts unlocked and unattended. Record review of Medication Labeling and Storage Policy dated 02/2023 revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review the facility failed to establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 3 residents (Resident # 17, #28, and #93) reviewed for antibiotic stewardship program.1. The facility failed to follow antibiotic stewardship policy by failing to include all required information per facility policy on their infection tracking log for Resident #17, Resident #28 and Resident #93.2. The facility failed to follow antibiotic stewardship policy for Resident #17, Resident #28, and Resident #93 by not ensuring an infection surveillance assessment was performed for all antibiotic orders.This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms.Findings included:Review of Resident #17's face sheet, dated 05/14/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body such as electrolyte imbalances, organ failure, nutritional deficiencies, or toxins in the blood), sepsis due to other specified staphylococcus (a serious medical condition characterized by a systemic infection caused by specific strains of staphylococcus bacteria), and bacteremia (the presence of bacteria in the bloodstream).Review of Resident #17's comprehensive MDS, dated [DATE], reflected a BIMS score of 13, which indicated no cognitive impairment. Section I - Active Diagnoses indicated Resident #17 had septicemia (an infection that occurs when germs get into the bloodstream and spread). Section N - Medications reflected Resident #17 had not received an antibiotic in the seven days prior to the assessment on 04/13/2026.Review of Resident #17's order summary, dated 05/14/2026, reflected the following order for an antibiotic: INVanz Injection Solution Reconstituted (Ertapenem Sodium) Use 0.5 gram intravenously one time a day related to METABOLIC ENCEPHALOPATHY for 8 Days INFUSE 50 ML OF SOLUTION ONLY TO EQUAL 500 MG TOTAL OVER 30 MINUTES DISCARD REMAINING with a start date of 05/13/2026 and stop date of 05/21/2026.Review of Resident #17's facility assessments reflected no infection screening evaluation assessment completed on or around 05/13/2026.Review of Resident #17's care plan on 05/14/2026 reflected no care plan related to metabolic encephalopathy or antibiotic to treat it.Review of Resident #28's face sheet, dated 05/14/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] with most recent readmission on [DATE], with diagnoses that included: nontraumatic intracerebral hemorrhage (spontaneous bleeding into the brain tissue), personal history of malignant neoplasm of brain (history of cancer in the brain), and laceration without foreign body of scalp (a cut or tear in the scalp tissue where no debris or foreign material are embedded).Review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 00, which indicated severe cognitive impairment. Section N - Medications reflected Resident #28 had received an antibiotic within the seven days prior to the assessment on 04/22/2026.Review of Resident #28's order summary, dated 05/14/2026 reflected the following order for an antibiotic: Cefepime HCl Intravenous Solution 1 GM/50ML Use 1 gram intravenously every 12 hours for scalp infection for 5 days with a start date of 05/12/2026 and a stop date of 05/17/2026.Review of Resident #28's facility assessment titled, Infection Screening Evaluation, dated 05/01/2026, reflected McGeer's Criteria (standardized guidance for infection surveillance) Met: Cellulitis (a bacterial infection of the skin), Soft Tissue or Wound Infection. No other Infection Screening Evaluations were completed for the month of May 2026.Review of Resident #28's care plan, dated 06/11/2025 and last revised 01/29/2026, reflected focus: I have a surgical wound related to recent surgery and I need support to promote healing and prevent complications. Location: Scalp. with interventions that included If antibiotics are prescribed, I will receive them as ordered and be monitored for effectiveness and side effects.Review of Resident #93's face sheet, dated 05/14/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: sepsis due to methicillin susceptible staphylococcus aureus (a bloodstream infection caused by a type of bacteria that is sensitive to methicillin antibiotics), urinary tract infection, and bacteremia.Review of Resident #93's MDS assessments reflected a comprehensive MDS had not yet been completed as of 05/14/2026.Review of Resident #93's order summary, dated 05/14/2026, reflected the following orders for antibiotics: ceFAZolin Sodium Injection Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for sepsis for 22 days with a start date of 05/07/2026 and stop date of 05/29/2026 and Clindamycin HCl Oral Capsule 300 MG Give 1 capsule by mouth three times a day for PNA [an infection that inflames the lung sacs in one or both lungs] for 7 days with a start date of 05/08/2026 and stop date of 05/15/2026.Review of Resident #93's facility assessment titled, Infection Screening Evaluation, dated 05/07/2026, reflected Loeb's Criteria(evidence-based guidance for starting antibiotics): Suspected Lower respiratory tract infection and a recent chest x-ray had been complete that reflected new infiltrates consistent with pneumonia. No other infection screening evaluations were completed for May 2026.Review of Resident #93's care plan, dated 05/07/2026, reflected a focus The resident has infection SEPSIS/UTI/MSSA bacteremia with interventions that included Administer antibiotics as per MD orders.Review of Resident #93's care plan, dated 05/07/2026, reflected a focus The resident has Pneumonia with interventions that included Give medications as ordered. Monitor/document for side effects and effectiveness.Review of facility Infection Control and Antibiotic Review, dated May 2026, reflected a table with the following titles for the columns, Resident Name, Room #, Antibiotic ordered, Diagnosis, # of days, Start Date, Stop Date, MD notified, Family notified, Acute care plan, Type of isolation, Water pictures [sic] are sanitized at least 2 times a week. Interview of staff reveals they are aware of the, Ice carts, resident equipment, enteral pumps, oxygen filters suction machine, nebulizers, Hskp. Disinfects rooms with d-diff[sic], blue top disinfectant being used for glucometers, The glucometer is sanitized between use using the purple tope [sic] disinfectant wipe, NO alcohol, Signage/PPE in place. Resident #28 was listed with her last name and first initial in the first column, her room number in the second column, Cefepime in the third column, wound infection in the fourth column, 10 in the fifth column, 5/2 in the sixth column, 5/12 in the seventh column, the eighth, ninth and tenth columns were marked with a check mark, Standard was under the eleventh column, and yes was in the remaining columns. Resident #93 was listed two times. The first appearance for Resident #93 reflected his last name in the first column, his room number in the second column, Clindamycin in the third column, PNA in the fourth column, 7 in the fifth column, 5/8 in the sixth column, 5/15 in the seventh column, the eighth, ninth and tenth columns were marked with a check mark, Standard was under the eleventh column, and yes was in the remaining columns. The second appearance for Resident #93 reflected his last name in the first column, his room number in the second column, Cefazolin in the third column, PNA in the fourth column, 22 in the fifth column, 5/7 in the sixth column, 5/29 in the seventh column, the eighth, ninth and tenth columns were marked with a check mark, Standard was under the eleventh column, and yes was in the remaining columns. Resident #17 was listed with her last name and first initial in the first column, her room number in the second column, Ertapenem in the third column, Metabolic Encephalopathy in the fourth column, the fifth column was left blank, 5/12 in the sixth column, the seventh and eighth column was left blank, the ninth and tenth columns were marked with a check mark, Standard was under the eleventh column, and yes was in the remaining columns.During a phone interview on 05/14/2026 at 04:15 PM, the DON stated she was certified and responsible for the infection prevention and control program until the ADON completed her training. She stated the ADON was supposed to complete the training by 05/17/2026. She stated antibiotic stewardship fell under the infection prevention and control program, so she was responsible for monitoring antibiotic stewardship. The DON stated when a new order for antibiotics was received, she ensured the infection met criteria, according to the infection screening evaluation. The DON stated if the infection did not meet the criteria, then she would contact the provider to discuss the use of antibiotics. When asked about the infection surveillance evaluation for Resident #17, she stated it should be in her assessments, if it is not there the charge nurse should have completed it. She stated the ADON was responsible for completing the infection surveillance evaluation if the charge nurse failed to complete it. The DON stated she followed up on the infection surveillance evaluations once they were completed. The DON stated she had not followed up on Resident #17's evaluation because she had only been in the position for a couple of weeks and had been busy working on chart reviews and staffing concerns. The DON stated she had delegated Infection Control and Antibiotic Review tracker to the ADON. While reviewing the Infection Control and Antibiotic Review tracker, the DON stated the tracker did not list the resident's medical record number, the date the symptoms appeared, the pathogen identified, an outcome to the antibiotic or any adverse events that may have occurred due to taking the antibiotics that was required per the facility's Antibiotic Stewardship policy. She stated not having the documentation per the facility policy could affect residents by residents having possible unknown adverse effects to the antibiotics or increase in symptoms from the infection. She stated if the infection screening evaluation was not completed, then the resident might not get treated with the right antibiotic or the resident could have a poor outcome.During an interview on 05/14/2026 at 05:39 PM, the ADON stated she was working on completing the training for the infection prevention and control certification and planned to complete the training by 05/17/2026. The ADON stated when an antibiotic order was received, she would check to see what the resident was on the antibiotic for and place the information on the Infection Control and Antibiotic Review tracker then updated the care plan. She stated she kept a log for when the residents completed their antibiotics. The ADON stated the DON gave her a mapping tool to track the antibiotics administered in the facility last week, but she had not had time to initiate the process yet. She stated she had reviewed the antibiotic stewardship policy maybe one time, but it was in her job duties. While reviewing the Infection Control and Antibiotic Review tracker, she stated the tracker did not include the resident's medical record number, the date the symptoms first appeared, the pathogen identified, the site of the infection, the date of the culture, the outcome, or any adverse event that occurred. She stated the tracker provided was not compliant with the antibiotic stewardship policy. The ADON stated the missing information could affect the resident because it could lead to another infection. She stated the nurse who received the order for the antibiotic was responsible for completing the infection screening evaluation. She stated she pulled the antibiotic report to ensure the infection screening evaluations were completed. She stated by not having the infection screening evaluation completed, the facility would have difficulty tracking when symptoms started and ensuring the correct tests were ordered. She stated it was the responsibility of the DON to ensure the Infection Control and Antibiotic Review tracker was completed correctly.During an interview on 05/14/2026 at 05:57 PM, the ADM stated he was filling in between administrators but was also the regional vice president of operations. He stated the DON was the infection preventionist, but the ADON was responsible for the antibiotic stewardship program. The ADM stated the antibiotic stewardship program was to ensure the facility had appropriate uses of antibiotics, they were not prescribed in overabundance and the antibiotics were effective. After reviewing the Infection Control and Antibiotic Review tracker, the ADM stated the following was not included per the facility policy for antibiotic stewardship: the medical record number, the date the symptoms appeared, the pathogen identified, the site of the infection, the date of the culture, the outcome, and the adverse effects. He stated the Infection Control and Antibiotic Review tracker did not meet his expectations to match the facility policy. The ADM stated he was unsure how the resident could be affected by the Infection Control and Antibiotic Review tracker not being completed per facility policy. He stated he was unaware of the procedure that occurred when an antibiotic order was received. The ADM stated if the use of antibiotic did not meet the criteria, then a resident could develop a multi drug resistant organism and potentially other infections.Record review of the facility's policy titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and last revised 2016, reflected Policy StatementAntibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.Policy Interpretation and Implementation1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee.2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.a. Therapy may require further review and possible changes if:(1) the organism is not susceptible to antibiotic chosen;(2) the organism is susceptible to narrower spectrum antibiotic;(3) therapy was ordered for prolonged surgical prophylaxis; or(4) therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics.4. All resident antibiotic regimes[sic] will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. resident name and medical record number; b. unit and room number; c. date symptoms appeared; d. name of antibiotic (see approved surveillance list); e. start date of antibiotic; f. pathogen identified (see approved surveillance list); g. site of infection; h. date of culture; i. stop date; j. total days of therapy; k. outcome; and l. adverse events.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were informed orally of their rights for 10 confidential residents reviewed for resident rights.The facility failed to ensure residents were provided with ongoing communication of their rights during their stay at the facility. This failure could place residents at risk for a decreased quality of life and awareness and execution of their rights.The findings included:A record review of resident council minutes indicated resident rights were not reviewed or discussed for the resident council meetings dated 05/22/2025, 07/16/2025, 08/19/2025, 09/16/2025, 12/08/2025, 01/08/2026, 02/12/2026, 03/11/2026 or 04/08/2026. The resident council minutes for October and November 2025 were not included in the records.During an observation on 05/12/2026 at 7:33 AM of the facility bulletin board revealed the resident rights posting was observed on the wall. During a confidential interview at an undisclosed date and time, 10 confidential residents indicated staff had not discussed or reviewed their rights with them. Seven of the 10 confidential residents stated they were unsure of which rights they had as a resident of the facility.During an interview on 05/14/2026 at 11:20 AM the AD indicated she was not aware she should have been reviewing and explaining residents' rights with residents until this morning. The AD stated she was unaware of the Ombudsman position, nor did she know the Ombudsman for the facility. The AD indicated she believed it was important for residents to know their rights. The AD indicated if residents did not know their rights, they would not be able to voice their concerns. During an interview on 05/14/2026 at 5:19 PM the SW stated she reviewed resident rights with residents and family members when they were unable to resolve a grievance. She stated she directed them to the Ombudsman. The SW stated she assumed the AD went over resident rights in the Resident Council meetings. The SW stated it was important for all residents to know their rights. During an interview on 05/14/2026 at 6:17 PM the ADM indicated the ADM trained all staff on resident rights. The ADM indicated his expectation was for the AD to review resident rights with the residents and provide them with ongoing information on the Ombudsman. The ADM indicated the risk to residents not knowing their rights could lead to resident rights being violated which could affect their psychosocial well-being and quality of life. A record review of the facility policy revised February 2021 titled Resident Rights indicated the following:Policy StatementEmployees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:H.be supported by the facility in exercising his or her rights;I. Exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. J. be informed about his or her rights and responsibilities.

Based on observation, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 6 of 8 confidential residents reviewed for homelike environment. The facility failed to ensure resident's wheelchairs were cleaned, free from dirt and debris. This failure could place residents at risk of diminished quality of life by living in an unsanitary and uncomfortable environment .Findings included: During a confidential interview at an undisclosed date and time, 1 confidential resident indicated the wheelchair locks do not work, the chairs are filthy and the staff never clean them. Seven additional residents of the 10 confidential residents stated their chairs have not been cleaned, one stated she had a toileting accident one day in her chair, and it did not get cleaned. Observation on 5/14/2026 at 10:34 AM of 8 wheelchairs revealed 6 wheelchairs to be unclean with significant accumulation of dust, hair, and other debris particles on the frames, between seat cushions and wheels of the wheelchairs. In an interview conducted on 05/14/2026 at 11:04 AM, The ADM stated the CNAs typically clean the wheelchairs; however, he will verify the facility's process. He stated he felt anyone who observed something dirty could clean it. The ADM stated he would check with the nursing administration regarding staff cleaning assignments and responsibilities.In an interview conducted on 05/14/2026 at 12:17 PM, LVN B stated the CNAs on the night shift typically clean the wheelchairs. She stated there is also a hospitality aide who passes out water, cleans wheelchairs, and answers call lights. LVN B stated some wheelchairs are clean and some are not. She stated staff make notes when wheelchairs are not clean and they are supposed to clean the wheelchairs when providing residents with showers. LVN B stated she has not personally cleaned any wheelchairs. She stated residents would not feel-good sitting in dirty wheelchairs and could be affected by the unclean conditions.In an interview conducted via phone on 05/14/2026 at 1:11 PM, hospitality aide stated she cleans wheelchairs at night on units 2 and 4. She stated she cleans the chairs with a blue spray. She stated she is mostly assigned to the secured unit downstairs.In an interview conducted on 05/14/2026 at 1:30 PM, RN A stated when she is working, she cleans wheelchairs as she works because she likes things to be clean. She stated that anyone can clean the wheelchairs; however, she feels all wheelchairs could use a deep pressure washing because food is frequently dropped in the chairs. RN A stated unclean wheelchairs can make residents feel uncomfortable.In an additional interview conducted on 05/14/2026 at 6:32 PM, The ADM stated the CNAs on the night shift are assigned responsibility for cleaning the wheelchairs. He stated staff had slacked in following the facility process for wheelchair cleaning. The ADM stated residents could experience some negative effects from the unsanitary conditions.Review of facility's policy named Homelike Environment revised February 2021 reflected: Policy StatementResidents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation2. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.3. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:6. clean, sanitary, and orderly environment;.

Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 17 (Resident #19 Resident #51 and Resident #61 ) residents reviewed for activities. The facility failed to provide a sufficient variety of activities, including evening and weekend activities to meet resident interests and psychosocial needs. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function.Findings included:Review of Resident #19's face sheet dated 5/12/2026 reflected an admission date of 12/12/2023 with diagnoses of major depressive disorder (sadness), psychotic disorder with hallucinations (seeing, hearing, or believing things that are not actually there), and generalized weakness. Review of Resident #19's MDS assessment dated [DATE], reflected Resident #19 had a BIMS score of 13 out of 15, and was cognitively intact. The MDS did not have any information on activities. Review of Resident #19's comprehensive care plan dated 01/29/2026, reflected resident has an activity focus area, with interventions of encourage participation in activities, assist to activities as needed, encourage engagement in meaningful activities and socialization, have activities that meet my physical and/or mental abilities, provide a program of activities that is of interest and accommodates residents. Interview conducted on 05/12/2026 at 11:56 AM, Resident #19 stated, she only participated in BINGO because they do not have any other activities, the Activity Director never tells them what is going on and does not invite them to any activities. The Mother's Day event never happened, and residents did not even know about Cinco De Mayo event because the calendar was not put up in time and nobody knew about the event.During another interview with Resident #19 on 05/14/2026 at 5:15 PM, she said they were supposed to have resident council meeting but that did not happen. Resident #19 stated the resident council meeting was the second Thursday of the month. Resident #19 stated not having activities makes her feel bad, bored, and left out. Record review of Resident #19's progress notes reflected the AD documentation of Resident #19 participating in only BINGO. Interview conducted on 05/14/2026 at 1:58 PM with LVN C stated they have BINGO every day except Sunday. The Activity Director has different volunteers that come in and call BINGO, they have a store for the residents to spend their winnings in. They have small activities like coloring. LVN C stated, the residents do not have enough activities to do, she had bed bound residents that have nothing to do. LVN C stated she did not see the Activity Director go to the residents to remind or encourage them to go to upcoming activities. Interview conducted on 05/14/2026 at 2:58 PM with AD, stated they have 4 activities a day, a lot of BINGO, activities involving food, music, and daily chronicles. For the bed bound residents, they like music and sometimes sensory bins. The AD stated she spends 30 - 40 minutes a couple times a week with bed bound residents. The AD said that the residents had music downstairs, and she said she did not know how the residents were to get downstairs for the activity. The AD stated the residents get to pick out what activities are done in their resident council meeting. The AD said a resident who did not have activities tailored to their needs could cause a decline in their health. She added most activities were tailored to the residents needs but not all of the activities. She said she would not like it if all she got to do was play BINGO. Interview conducted on 05/14/2026 at 4:56 PM, CNA F stated there is not enough for the residents to do and what they do have is dictated by 1 or 2 residents. CNA F stated the residents often state they are bored. CNA F stated the residents could have a decline in health if their needs are not met psychosocially. Interview conducted on 05/14/2026 at 5:30 PM with ADM stating expectations are to have activities tailored to meet every resident's needs, if not met the residents' health could decline as well as their psychosocial wellbeing. Review of Resident #51's face sheet dated 05/12/2026 reflected an admission date of 10/18/2024 with diagnoses of Parkinson's disease (condition that affects how a person moves), dysphagia (trouble swallowing), and generalized weakness. Review of Resident #51's MDS assessment dated [DATE], reflected Resident #51 had a BIMS score of 10, indicating moderate cognitive impairment. There was nothing on the MDS about activities. Review of Resident #51's comprehensive care plan dated 03/10/2026, reflected resident has an activity focus area, with interventions of encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, and the resident is dependent on staff for activities, cognitive stimulation, social interaction related to mobility. Interview conducted on 5/12/2026 at 8:02 AM, Resident #51 stated he had lived there for almost 2 years, he said he joined activities but not enough of activities. Resident #51 said he did not feel anything about activities but would like to see different activities besides BINGO. Review of Resident #61's Face sheet dated 05/12/2026 reflected an admission date of 03/31/2022 with diagnoses of end stage renal disease (final irreversible stage of kidney failure), legal blindness (disease of eye), Type II Diabetes Mellitus with Diabetic Retinopathy without macula edema (damage to blood vessels in retina), generalized muscle weakness. Review of Resident #61's MDS assessment, dated 04/09/2026, reflected Resident #61 had a BIMS score of 15 out of 15, and was cognitively intact. The MDS did not have any information about activities. Review of Resident #61's comprehensive care plan dated 05/12/2026, reflected resident has an activity focus area, with interventions of Have activities that meet my physical and/or mental abilities and Provide, invite and encourage my activity preferences. Interview conducted on 05/12/2026 at 10:43 AM, Resident #61, stated the facility mostly offers BINGO as an activity of choice. He stated he does not attend BINGO because he is blind and unable to participate in the activity. He stated one of the previous social workers ordered him blind friendly activity materials.Record review of the Facility Dignity Policy dated 02/2021 revealed When assisting with care, residents are supported in exercising their rights. Residents are: encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #38) reviewed for PASRR assessments. The facility did not complete a 1012 form (used by the state nursing facilities to review residents with a negative PASRR Level 1 screening and determine if further evaluation for mental illness or dementia is needed) to update resident #38's PASRR Level 1 with the newly evident mental health diagnosis.The facility did not refer Resident #38 to the appropriate state-designated mental health authority for review when she received a new diagnosis of Major Depressive disorder, recurrent severe (condition where person experiences repeated episodes of very intense sadness, loss of interest, low energy, and feelings of hopelessness) during her stay at the facility on 03/06/2025.The failures could place residents who had a mental illness at risk of not being evaluated and receive needed PASRR services.Findings included:Record review of Resident #38's Face sheet printed on 05/13/2026 reflected a [AGE] year-old female, admitted to facility on 06/14/2024. Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), generalized anxiety disorder (a mental health condition where feelings of intense fear and worry are constant, overwhelming, and interfere with daily life), unspecified psychosis (a condition difficulty distinguishing what's real and what's false, symptoms do not fully match another psychotic disorder), and major depressive disorder(persistent low mood or lack of interest in activities, significantly affecting a person's ability to function in daily life . The diagnosis for Major Depressive disorder had an onset date of 03/06/2025. Record review of Resident #38's MDS dated [DATE] reflected the resident had a BIMS of 11, which indicated moderate cognitive impairment. Record review of Resident #38's Care Plan printed on 05/13/2026 reflected no focus area for Major Depressive Disorder with related person-centered goals and interventions. Record review of Resident #38's only PASRR Level I, dated 06/13/2024, reflected she did not have any mental illness. Record review of Resident #38's level 2 PASRR indicated it was completed 10/22/2015 and the resident had a mood disorder.In an interview conducted 5/13/2026 at 5:53 PM with the MDS RN and MDS LVN, they stated they realized PASRR Level II was outdated that was provided to the surveyor earlier in day. The MDS RN stated the PASRR II was completed during one of Resident #38's skilled stays many years ago prior to their employment at the facility. The MDS RN stated Resident #38's new mental health diagnosis had been missed regarding the PASRR review. She stated she completed form 1012 and it had been submitted and a new PASRR Level II evaluation would be completed. In an interview conducted 5/14/2026 at 9:49 AM, the DON stated the MDS nurses were responsible for PASRR referrals to the appropriate state-designated authority. She stated she was new to her role as the DON, and she as unsure of the process for referring residents with new mental health diagnosis acquired during their stay. The DON stated the nursing department did monitor and make observations for new behaviors and they would notify the doctor of any changes and complete psychological referrals as needed. An additional interview conducted 5/14/2026 at 1:45 PM, the MDS RN stated when asked how the facility identified residents with newly evident possible mental illness (MI), intellectual disability (ID), or related conditions after admission, that the nursing department was hands-on and should notify the physician or nurse practitioner of any changes in behaviors or condition. She stated the physician, nurse practitioner, and nursing staff were actively involved with residents. The MDS RN stated historically the MDS department completed referrals to the appropriate state designated authority when a resident was identified as having a mental health diagnosis. She stated if a resident was identified as having a newly evident mental health diagnosis, the information is entered into SimpleLTC(portal used by nursing facilities to manage information) the MDS RN stated she and the MDS LVN spoke with the corporate consultant the previous night and developed a new process that morning to help identify new diagnoses and establish a referral system. She stated they had already reviewed 24-hour reports for new orders. The MDS RN stated they had a contracted Counseling Service that visited the facility monthly and residents were referred through social services. She stated the physician, nurse practitioner, and nursing staff make referrals to social services, who then submit referrals for psychological services. She stated moving forward, when the contracted Counseling Service visits the facility, an interdisciplinary conference would be completed that includes the DON and SW to discuss any changes and determine needed interventions. She stated any new diagnosis would require completion of Form 1012. The MDS RN stated prior to the process there had been no formal notification system in place. She stated failure to complete the proper PASRR assessments could result in residents missing specialized services.Review of the facility's policy titled, PASRR dated 1/20/2026 reflected: PurposeThe aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. ProcedureThe PASRR Level 1 Screen (PL1) The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 upon admission. The MDS Coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s, and PL1s for residents who qualify for exempted or expedited status. In the event of a positive PL1 that indicates the individual may have ID/DD or MI;1. The MDS Coordinator, Social Worker, or designee will.a. Notify the LIDDA or LMHA/LBHA within 2 calendar days of admission to schedule the IDT and initiate the PE process.b. Monitor the Simple portal daily for the PEc. Will review the PE, print the form and place in the medical record.3. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings.

Based on interview and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with a mental illness was completed correctly and were provided with a PASRR Level II assessment for one (Resident #7) of 8 residents reviewed for PASRR assessments.The facility failed to ensure the MDS RN entered Resident #7's PASRR Level l correctly into SimpleLTC portal (portal used by nursing facilities to manage resident's information) the PASRR entered did not indicate a diagnosis of mental illness, although diagnosis was present upon admission. This failure could place all residents who had a mental illness at risk for not receiving needed assessment, care, and services to meet their needs.Findings included: Record review of Resident #7's Annual MDS Assessment, dated 02/10/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 05, indicative his cognitive skills were significantly impaired. His diagnoses included stroke, anxiety disorder (excessive, uncontrollable worry), and depression (feelings of sadness, loss of interest).Record review of Resident #7's PASRR Level 1 screening, completed 06/10/2024 by the SW of referring facility, reflected the resident had a mental illness. Record review of Resident #7's PASRR Level 1 screening entered by the facility's MDS RN on 6/10/2024 reflected the resident did not have a mental illness. In an interview on 04/28/26 at 10:31 AM, the MDS Coordinator said the resident had a negative PASRR Level 1 and it was not correct based on the resident's diagnosis. The MDS Coordinator said she missed the diagnosis and did not submit a new PASRR Level 1 screening. The MDS Coordinator said a negative PASRR Level 1 screening could cause residents to miss PASRR services.In an interview conducted 5/14/2026 at 9:49 AM, the DON stated the MDS nurses were responsible for PASRR referrals to the appropriate state-designated authority when a resident was identified with a mental health diagnosis. The DON stated the nursing department did monitor and make observations for new behaviors and they would notify the doctor of any changes and complete psychological referrals as needed. In an interview conducted 5/14/2026 at 1:40 PM, the MDS RN clarified the first PASRR Level 1 screening prepared by Resident #7's referring nursing facility was correct, if that resident had a mental health diagnosis. The MDS RN further stated it was her fault that the mental health diagnosis was not on the second copy of the PASSR Level 1 that she inputted into SimpleLTC. She stated she would complete form 1012 (used by the state nursing facilities to review residents with a negative PASRR Level 1 screening and determine if further evaluation for mental illness is needed) for Resident #7 on that day. The MDS RN stated a negative PASRR Level 1 screening could cause residents to miss PASRR services.Review of the facility's policy titled, PASRR dated 1/20/2026 reflected: PurposeThe aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID), or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. ProcedureThe PASRR Level 1 Screen (PL1)The facility Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 upon admission. The MDS Coordinator or designee will input all other PL1s into the online portal on admission. This includes negative preadmission PL1s, and PL1s for residents who qualify for exempted or expedited status. In the event of a positive PL1 that indicates the individual may have ID/DD or MI.2. The MDS Coordinator, Social Worker, or designee will.d. Notify the LIDDA or LMHA/LBHA within 2 calendar days of admission to schedule the IDT and initiate the PE process.2.When it is determined that a PL1 was filled out incorrectly, the MDS Coordinator, Social Worker or designee will reach out to the hospital/responsible case worker and ask them to correct the form. a. If the referring case worker is unwilling/unable to correct the PL1 that contains a potential error, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings (MI).

Based on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 17 (Resident #23) residents reviewed for medication administration. The facility failed to ensure staff did not leave medication with Resident #23 when there was not a self-administer assessment completed. This failure could place residents at risk of not accurately receiving their medications, which could cause a change in condition.Findings Included: Record review of Resident #23's face sheet dated 05/14/2026 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #23 had diagnoses which included seizures, difficulty in walking, anxiety (feeling of uneasiness or worry), major depressive disorder (mental health disorder characterized by persistent depressed mood), headaches, cancer, and hypertension (high blood pressure). Record review of Resident #23's admission MDS dated [DATE] revealed Resident #23 had a BIMS score of 13, which indicated intact cognitive response. The MDS indicated Resident #23 did not have any swallowing issues with medications. Record review of Resident #23's care plan dated 5/11/2026 revealed [Resident #23] was at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment, medication side effects, poor vision, or incontinence. Staff will monitor [Resident #23] more closely, especially during high-risk times such as shift changes, night hours, or after medications. The care plan did not say Resident #23 could self-administer medications. Record review of Resident #23's assessments on 05/12/2026 revealed that Resident #23 did not have a self-administration assessment completed. Observation of Resident #23's room on 05/12/2026 at 8:34a.m., revealed that he had a medication cup with a white liquid in it, another medication cup with a green gel capsule in it and a prescription nasal spray. During an interview with Resident #23 on 05/12/2026 at 8:49a.m., he said staff did not always leave his medication with him. He said the facility told him that he could not self-administer his medication. He said the medication the nurse left was medication that he had to take right after he ate breakfast. He said the medication was medication he needed for his stomach he did not know the names of the medication. He said the medication was left at times when the nurse does not have time to come back and give him his medication on time. During an interview with the DON on 05/14/2026 at 10:14a.m., she said she had been trained on medication administration. She said the policy for medication administration was staff were not to leave medication with a resident. She said the nurse or the MA who was giving the medication was responsible for ensuring the resident took the medication. She said if the medication was left with the resident and the nurse did not watch the resident take the medication the resident could throw the medication away. She also added another resident could get ahold of the medication and take it. She said the DON monitored to ensure that staff were not leaving medication with the residents. She said the DON monitored through observations. She said she did not know why left the medication with Resident #23. During an interview with the ADM on 05/14/2026 at 11:41a.m., he said he had been trained on medication administration. He said the policy for medication administration was staff were to watch the resident take medication and not leave any medication with the resident. He said the nurse was responsible for ensuring medication was not left with the resident. He said if medication was left with a resident, the resident may not take the medication. He said the ADM and DON monitored to ensure staff were not leaving medication with residents. He said the ADM and the DON monitored through daily rounds. He said he did not know why left medication with Resident #23. An interview was attempted with LVN I on 05/14/2026 at 2:33p.m., via telephone was unsuccessful. An interview was attempted with LVN I on 05/14/2026 at 3:19p.m., via telephone was unsuccessful. Record review of Administering Medications Policy dated 04/2019 revealed Medications are administered in a safe and timely manner, and as prescribed. Residents' may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 dining rooms reviewed for infection control. The facility failed to ensure CNA D washed and sanitized her hands between passing breakfast trays to the residents. The facility failed to ensure CNA E washed and sanitized her hands between passing breakfast trays to the residents. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: During an observation of dining services for breakfast meal services on 05/12/2026 at 7:44a.m., revealed CNA D and CNA E did not wash or sanitize their hands while passing meal trays to residents in the dining room. During an interview with the DON on 05/14/2026 at 10:02a.m., she said she had been trained on hand hygiene. She said the policy for hand hygiene during meal services was staff were to wash their hands before they started passing the meal trays. She also said staff were to sanitize their hands between each meal tray. She said anyone who was touching the meal trays should be washing and sanitizing their hands. She said if staff were not performing hand hygiene the staff could spread infection or cause someone to get sick. She said the nurse monitored to ensure staff were sanitizing their hands. She said the nurse monitored through observation. She said she did not know why CNA D and CNA E did not wash or sanitize their hands before or during meal tray pass. During an interview with CNA E on 05/14/2026 at 10:21a.m., she said she had been trained on hand hygiene. She said the policy for meal tray pass was staff were to sanitize their hands between each meal tray. She also added that if staff's hands were physically dirty the staff was to wash their hands with soap and water. She said anyone handing out the meal trays was responsible for sanitizing their hands. She said if staff did not perform hand hygiene, the staff could pass an infection that another resident may have to other residents. She said the nurses or management monitored to ensure staff were washing and sanitizing their hands. She said the nurses or management monitored by observation. She said she did not wash or sanitize her hands because she was just moving fast. During an interview with the ADM on 05/14/2026 at 11:34a.m., he said he had been trained on hand hygiene. He said his expectation was for staff to use an alcohol-based sanitizer between each meal tray. He said all staff who were assisting with passing trays must sanitize their hands. He said if staff did not perform hand hygiene between meal trays it could put the resident at risk of cross contamination. He said the department heads monitored to ensure staff were sanitizing hands between meal trays. He said the department heads monitored through observation. He said he did not know why CNA D and CNA E were not washing or sanitizing their hands between meal trays. During an interview with CNA D on 05/14/2026 at 3:55p.m., she said she had been trained on hand hygiene. She said the policy was that staff were to wash their hands between each meal tray and keep their hand sanitizer in their pocket. She said the CNAs were responsible for sanitizing their hands between each meal tray. She said if staff did not perform hand hygiene the residents could get an infection. She said the nurse monitored to ensure staff were washing and sanitizing their hands. She said the nurse monitored through observation. When asked why she did not wash or sanitize her hands before meal trays were passed or between each resident she said she got sanitizer from the nurse to sanitize her hands. Record review of Handwashing/Hand Hygiene Policy dated 01/2025 revealed This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for 2 (Residents #63 and #65) of 8 residents reviewed for privacy and confidentiality. The facility failed to ensure that the Resident Identifier sheet and corresponding survey containing PHI of Residents #63 and #65 were not left in the public survey binder in the lobby of the facility. The failure could place the residents at risk of their medical information being exposed to unauthorized individuals.Findings included: Record review of Resident #63's Face Sheet, dated 05/13/2026, reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Diabetes Mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), and hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Review of Resident #63's quarterly MDS dated [DATE] reflected Resident #63 was assessed to have a BIMS score of 04 indicating she had severe cognitive impairment. Review of Resident #65's face sheet dated 05/13/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Ogilvie syndrome (An intestinal pseudo-obstruction feels like something is physically blocking your bowels. But they are not actually obstructed because they are paralyzed.), hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) following a cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) Review of Resident #65's annual MDS assessment dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 14 indicating he was cognitively intact. Observation and review on 05/13/2026 at 8:45 a.m. of the public survey binder revealed it was in the foyer of the facility. Review of the binder revealed it contained a resident identifier sheet with a list of resident names and numbered identifiers as well as the survey/investigation for that identifier sheet with PHI (medical diagnoses) in the survey/investigation.During an interview with the DON on 5/14/2026 at 9:49 AM, the DON stated she had been with the facility for a month and was unsure who was responsible for maintaining the survey binder at the facility but at previous facilities it was the ADM. The DON stated PHI was information that was not available to the public as residents at the facility had a right to privacy. She stated the survey binder should not have residents' names inside. She stated if she was to discover that information in the binder, she would remove it immediately and she would in-service staff immediately to ensure staff were trained to safeguard the information. The DON stated having confidential information left out where the public could review could lead to legal issues. During an interview with the ADM on 05/14/2025 at 11:05 AM, he stated the survey binder as usually monitored by the ADM or the DON. He stated he was unaware of the confidential resident Identifier form, containing the residents' names and identifiers had been left in the survey binder. The ADM stated the potential effect of confidential information being accessible to visitors, residents, or others could affect residents' rights to confidentiality. He stated the document stapled to the report was likely the only indicator identifying the two residents to the report. He stated staff were trained as needed on confidentiality and its covered in orientation.A record review of the facility policy revised February 2021 titled Resident Rights indicated the following: Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: t. privacy and confidentiality;. Record review of the facility's policy Compliance Risks - Privacy, Security, and Breach Notifications, dated January 2025 indicated:Policy StatementThe facility complies with the laws governing privacy, security, and breach notification of protected health information as set forth in the Health Insurance Portability and Accountability Act (HIPAA) and other privacy and security rules.Policy Interpretation and Implementation1. The facility maintains policies and practices protecting the use and disclosure of protected health information and breach notifications in accordance with the Health Insurance Portability and Accountability Act (HIPAA).2. The facility maintains policies and procedures ensuring resident privacy and confidentiality in accordance with the Requirements of Participation, including:a. maintaining the privacy and confidentiality of resident medical records (42 CFR 483.10(h) and 483.70(h)); 3. Personnel are trained in the policies and practices that protect the privacy, confidentiality, and security of resident-identifiable information throughout the facility

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 25 residents (Resident #29 and Resident #63) reviewed for resident rights.The facility failed to ensure CNA D knocked on Resident #63's door before entering the resident's room.The facility failed to ensure staff assisted Resident #29 with removing his hospital gown and putting on his clothing as preferred on .5/13/2026 and 5/14/2026. This failure could place residents at risk of feeling like their privacy was invaded, cause emotional distress, diminished feelings of self-worth and/or diminished quality of life. Findings Included:1. Record review of Resident #29's MDS Assessment, dated 03/17/2026, reflected he was an [AGE] year-old male, admitted [DATE] with a BIMS score of 03, which indicated severe cognitive impairment. The resident's diagnoses included Transient Cerebral Ischemic attack (temporary blockage of blood flow to brain), Non-Alzheimer's Dementia (cognitive decline, confusion), muscle weakness, and hypertension (high blood pressure).Observation/Interview conducted with Resident #29 on 5/12/2026, at 9:04 AM, revealed the resident was observed sitting in bed with his gown on. He stated he was doing fine.Observation conducted with Resident #29 on 5/13/2026, at 10:15 AM, revealed the resident was observed in bed with his gown on.Observation/Interview conducted with Resident #29 on 05/13/2026, at 3:13 PM revealed Resident #29 was observed in his bed with his gown on. The resident mumbled words to the surveyor, holding his gown, and it was noted to have feces on it. The surveyor notified staff of the resident's condition, and the DON went to the room with another nursing staff to assist resident in being changed Observation/Interview conducted with Resident # 29 on 05/14/2026, at 12:22 PM revealed the resident was observed to be in bed with his hospital type gown on. The resident stated he wanted to get out of bed, and when asked if he wanted to put on clothes, he responded, yes. The resident's closet was noted to have clean clothes hanging inside.In an interview conducted with Resident #29's family member on 05/13/2026, at 09:42 AM. The resident's family member stated she had concerns regarding Resident #29 remaining in bed all the time. The family member stated the facility did not get Resident #29 out of bed regularly. She stated the resident had previously been receiving therapy services; however, therapy was discontinued and the resident had since declined. The family member stated staff informed her they did not place the resident in his wheelchair because he frequently rolled into other residents' rooms and staff stated to her, they did not have enough staff to only keep up with him. The family member stated her concern was that leaving the resident in bed all day could place the resident at risk for bed sores, further decline in mobility, and decreased quality of life.2. Record review of Resident #63's face sheet, dated 05/14/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included type 2 diabetes mellitus without complications (high blood sugar), muscle weakness, difficulty in walking, lack of coordination, cognitive communication deficit (problems with communication), hyperlipidemia (high cholesterol), and hypertension (high blood pressure).Record review of Resident #63's quarterly MDS assessment dated [DATE] revealed Resident #63 had a BIMS score of 4, which indicated severe cognitive impairment.Observation on 300-hall on 05/12/2026 at 7:47a.m., revealed CNA D did not knock on Resident #63's door before entering the room.During an interview conducted with the DOR on 5/14/2026, at 9:25 AM, the DOR stated the therapy department got Resident #29 out of bed 5 days a week when he was completing physical therapy. She stated Resident #29 reached his 100 days and it ended after no progress. The DOR stated it was now up to the nursing department to get the resident up and out of bed.During an interview with the DON on 05/14/2026 at 9:58a.m., revealed she had been trained on resident rights. She said the policy for knocking was that staff were to knock on the door and wait to enter. She said if the resident did not answer, staff should knock again. She said everyone was responsible for knocking on the resident's door. She said if staff did not knock residents may feel like their privacy or rights were not being respected. She said the DON monitored to ensure staff were knocking. She said the DON monitored through observation. She said she did not know why CNA D did not knock before going into Resident #63's room. During an interview with CNA D on 05/14/2026 at 10:18a.m., she said she had been trained on resident rights. She said the policy was to knock before entering the room and wait until the resident answered before going in. She said all employees were responsible for knocking before entering the resident's room. She said if staff did not knock the resident may feel violated. She said the nurses and management monitored to ensure staff were knocking. She said the nurses and management monitored through observation. She said she did not knock on Resident #63's door because she just moving fast sometimes. During an interview with Resident #63 on 05/14/2026 at 11:10a.m., she said that staff never knocked on her door before entering. She said she wanted staff to knock all the time. She said she felt like she was being violated when staff did not knock. She said staff would come in and she would not know why they would be there. During an interview with the ADM on 05/14/2026 at 11:21a.m., he said he had been trained on resident rights. He said the policy for knocking was staff were to knock before entering and wait for a response. He said everyone was responsible for knocking on the resident's door. He said depending on the resident it may not bother some if staff did not knock. He added it might bother other residents. He said the resident may feel like they do not have a sense of privacy. He said the leaders and peers monitored to ensure staff were knocking. He said leaders and peers monitored through observation. He said he did not know why CNA D did not knock on Resident #63's door before entering.During an interview conducted with LVN B on 5/14/2026, at 12:26 PM, LVN B stated she did not believe Resident #29 remained in bed all the time during her shift rotation. LVN B stated the resident was often up and entered other residents' rooms. She stated the CNAs were responsible for dressing the resident and that Resident # 29 required assistance from two to three staff members. LVN B stated one reason the resident may not be dressed was because his clothes may not have been washed or returned from laundry services. She further stated there were times when the resident was asleep and remained in bed. LVN B stated it was not appropriate for residents to remain in a gown all day unless there was a laundry issue. She stated at the time of the interview the resident remained in bed because she was unable to safely get him up by herself and was not comfortable attempting to transfer him alone while the aide was at an appointment.During an interview conducted with CNA D on 5/14/2026, at 12:44 PM, CNA D stated Resident #29 required assistance from two to three staff members for transfers and changes. CNA D stated the resident got up sometimes; however, she was unsure how the resident felt about wearing a gown throughout the day. She stated, long as he is covered, she believed it was acceptable because the resident had not made any complaints regarding wearing a gown all day. During an interview conducted with CNA E on 5/14/2026 at 3:51 PM, CNA E stated she worked for the facility 26 years come July 30, 2026. CNA E stated there was no particular reason why Resident #29 was not assisted with getting out of bed. CNA E stated Resident #29 went from room to room and other residents complained about him entering their rooms, so staff often kept him in bed because female residents scream and holler. CNA E stated this information had been discussed with the resident's family member. CNA E further stated there are times when staffing was limited, and with only three staff members available, they were unable to continuously redirect or monitor the resident from entering other residents' rooms. CNA E stated Resident #29 frequently wore a gown because his shirts were dirty and it was easier to leave him in the gown. CNA E stated she would rather not wrestle with the resident and it was easier for him to remain in the gown. She stated she did not know of any potential effect on the resident. During an additional interview conducted with Resident #29's family member on 05/14/2026, at 04:14 PM, the family member stated the facility washed Resident #29's clothes. She stated he had clean clothes in his closet and on a shelf in his restroom. The family member stated Resident #29 went to the doctor on Tuesday,05/12/2026 and the doctor gave orders for him to be dressed daily to prevent him from pulling his catheter. The family member stated she had spoken to LVN C and the Social Worker about the orders and concerns.In an interview conducted with DON on 5/14/2026, at 4:56 PM the DON stated she was not aware of any physician's order for clothing. She stated she would not have accepted an order of such nature as there was no reason a resident should not put on clothes. The DON stated her expectation was for the nursing staff to assist residents out of bed and ensure residents were dressed in regular clothing. She stated it was not acceptable for a resident to remain in a gown every day. The DON further stated keeping Resident #29 in bed to prevent him from entering other residents' rooms was not an acceptable reason, and staff should redirect the resident instead. The DON stated she was new to the facility and was in the process of implementing multiple changes. She stated that anyone having to remain in a gown every day would likely not feel good about themselves. In an interview conducted with LVN C on 5/14/2026, at 5:08 PM. LVN C stated Resident #29 was dressed in pants during her rotations and the pants kept the resident from pulling at his Foley catheter. She stated being in a gown all the time could make a person feel bad. Record review of the facility policy Activities of Daily Living (ADL), Supporting, revision date of February 2025 revealed the following [in part]:Policy StatementResidents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Policy Interpretation and ImplementationResidents will be provided with care, treatment, and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. Unavoidable decline may occur if he or she:a natural progression of a debilitating disease with known functional declinehas suffered the onset of an acute episode that caused physical or mental disability and is receiving care to restore or maintain functional abilities; and/orDepression is a potential cause of excess disability, and, where appropriate, therapeutic interventions should be initiated.refuses care and treatment to restore or maintain functional abilities and:the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; andhe or she has been offered alternative interventions to minimize further decline; andthe refusal and information are documented in the resident's clinical record.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:hygiene (bathing, dressing, grooming, and oral care).mobility (transfer and ambulation, including walking).elimination (toileting).dining (meals and snacks); andcommunication (speech, language, and any functional communication systems).4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate.Record review of the Dignity Policy dated 02/2021 revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Staff are expected to knock and request permission before entering residents' rooms.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biological) to meet the needs of each resident for one of four residents (Resident #1) reviewed for medications and pharmacy services.The facility failed to ensure Resident #1 had his prescribed clonidine (a medication for high blood pressure) 0.3mg/24HR transdermal (applied to the skin) patches available for administration.This failure could place residents at risk of not receiving the intended therapeutic benefits of the medication and symptomatic changes in vital signs.Findings included:Record review of Resident #1's face sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic kidney disease, unspecified (the gradual loss of kidney function), essential hypertension (high blood pressure), and unspecified atrial fibrillation (irregular heart rhythm).Record review of Resident #1's comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment.Record review of Resident #1's order summary, dated 04/01/2026, reflected clonidine Transdermal Patch Weekly 0.3 MG/24HR (Clonidine) Apply 1 patch transdermally one time a day every Sat related to ESSENTIAL (PRIMARY) HYPERTENSION with an order date of 01/12/2026 and start date of 01/17/2026; Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 60 MG Give 1 tablet by mouth two times a day for chest pain Do not crush. Hold SBP<110, HR<60, Metoprolol Tartrate Oral Tablet 100 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION Hold SBP <110, HR <60,Furosemide Oral Tablet 40 MG Give 1 tablet by mouth two time a day for BLE swelling, and Spironolactone Oral Tablet 25 MG Give 0.5 tablet by mouth one time a day for swelling.Record review of Resident #1's comprehensive care plan, dated 01/12/2026 and last revised 03/30/2026 reflected a focus area of The resident has hypertension (HTN) with interventions that reflected Give anti hypertensive medications as ordered.Record review of Resident #1 medication administration record for March 2026 reflected Resident #1 was scheduled to receive clonidine Transdermal Patch on 03/09/2026, 03/14/2026, 03/21/2026, and 3/28/2026, but did not receive the medication. Instead, the area to indicate the medication was administered was marked with 9 and initials. The key at the bottom of the medication administration record reflected 9 indicated medications not available.Record review of Resident #1's blood pressures for March 2026 reflected:03/01/2026 11:04 AM - 141/70 mmHg03/01/2026 07:50 PM - 145/72 mmHg03/02/2026 11:59 AM - 123/66 mmHg03/02/2026 05:12 PM - 148/70 mmHg03/03/2026 08:46 AM - 169/79 mmHg03/03/2026 07:04 PM - 148/84 mmHg03/04/2026 09:10 AM - 166/71 mmHg03/04/2026 05:09 PM - 166/88 mmHg03/05/2026 12:11 PM - 132/88 mmHg03/06/2026 11:47 AM - 152/85 mmHg03/06/2026 07:02 PM - 130/63 mmHg03/07/2026 12:33 PM - 154/84 mmHg03/07/2026 05:26 PM - 116/62 mmHg03/08/2026 09:30 AM - 136/66 mmHg03/08/2026 04:28 PM - 162/75 mmHg03/09/2026 11:06 AM - 153/92 mmHg03/09/2026 08:11 PM - 158/86 mmHg03/10/2026 01:28 PM - 141/79 mmHg03/11/2026 11:15 AM - 127/79 mmHg03/11/2026 06:15 PM - 137/71 mmHg03/12/2026 08:28 AM - 162/70 mmHg03/12/2026 05:54 PM - 145/88 mmHg03/13/2026 07:41 AM - 144/65 mmHg03/13/2026 09:27 PM - 142/75 mmHg03/14/2026 12:44 PM - 145/78 mmHg03/14/2026 06:16 PM - 146/79 mmHg03/15/2026 01:15 PM - 144/62 mmHg03/15/2026 06:27 PM - 163/68 mmHg03/16/2026 12:50 PM - 150/83 mmHg03/16/2026 06:10 PM - 147/83 mmHg03/17/2026 12:31 PM - 145/65 mmHg03/17/2026 10:19 PM - 140/66 mmHg03/18/2026 07:27 PM - 144/64 mmHg03/19/2026 12:11 PM - 155/80 mmHg03/20/2026 12:35 PM - 152/80 mmHg03/20/2026 06:36 PM - 149/71 mmHg03/21/2026 12:26 PM - 167/76 mmHg03/21/2026 08:02 PM - 170/79 mmHg03/22/2026 09:10 AM - 145/76 mmHg03/22/2026 04:53 PM - 117/63 mmHg03/23/2026 01:31 PM - 142/68 mmHg03/23/2026 07:22 PM - 144/64 mmHg03/24/2026 12:10 PM - 138/77 mmHg03/24/2026 07:53 PM - 146/82 mmHg03/25/2026 08:30 AM - 161/76 mmHg03/25/2026 07:55 PM - 141/72 mmHg03/26/2026 12:19 PM - 154/76 mmHg03/26/2026 08:24 PM - 154/78 mmHg03/27/2026 01:10 PM - 161/74 mmHg03/27/2026 09:03 PM - 156/74 mmHg03/28/2026 12:47 PM - 122/64 mmHg03/28/2026 09:04 PM - 150/78 mmHg03/29/2026 02:13 PM - 148/81 mmHg03/29/2026 07:00 PM - 148/85 mmHg03/30/2026 01:25 PM - 182/78 mmHg03/30/2026 05:32 PM - 161/74 mmHg03/31/2026 10:55 AM - 127/61 mmHg03/31/2026 05:50 PM - 191/99 mmHgDuring an interview on 04/01/2026 at 02:10 PM, Resident #1 stated the facility had changed pharmacies recently and he had concerns about not receiving his patch for his blood pressure. He stated he had not received the patch in over a week, and he thought his blood pressure was elevated due to the missed patch. He stated he did not currently have a patch on. During an observation on 04/01/2026 at 06:15 PM of the unit 3 medication cart revealed a box of clonidine 0.3mg/24hr patches with 3 patches inside and labeled with Resident #1's name and dated 03/10/2026 in the top left drawer in the front left corner.During an interview on 04/02/2026 at 06:30 PM, the DON stated she was unsure what 9 indicated on the MAR. She stated she was not aware that Resident #1 had missed his clonidine patch for the month of March 2026. She stated she was going to go check on Resident #1.During an interview on 04/02/2026 at 07:55 PM, the DON stated Resident #1's clonidine patches were located in the unit 3 medication cart and she had moved it to the unit 3 nurse's cart and moved the medication to the nurse's MAR. She stated she did a skin assessment on Resident #1 and was unable to locate a clonidine patch.During a phone interview on 04/02/2026 at 10:39 AM, MA C stated she was responsible for applying the transdermal patch to Resident #1 on 03/14/2026 and 03/28/2026. She stated the patches were unavailable during medication administration time and she notified her charge nurse that day of the missing medication. MA C stated she was aware that LVN D had contacted the pharmacy within the last month about the missing medication but was unsure when or the outcome of the call. MA C stated she was unsure if the provider was notified each time the medication was not available. MA C stated the patches were located on the evening of 3/29/2026 in the unit 3 nurses medication cart by LVN E. MA C stated she was not sure if the medication was applied to Resident #1 when found by LVN E. MA C stated Resident #1 did not make any complaints to her related to the missing medication. She stated she regularly assessed Resident #1's blood pressure during medication administration and had not seen his blood pressure out of range. MA C stated the nurse attempted to pull the medication from the emergency kit, but the medication was not stocked in the emergency kit.During an interview on 04/02/2026 at 11:30 AM, MA B stated a 9 on the medication administration record indicated a medication was not available for administration at that time. She stated she was responsible for administering medication to Resident #1 on 03/07/2026 but was unable to administer the clonidine 0.3mg/24hr medication due to it not being in the medication cart. MA B stated she notified LVN D that day of the unavailability of the medication but did not remember the response from LVN D when notified. She stated the policy for medication administration was to notify the nurse if a medication was not available. MA B stated if Resident #1's clonidine transdermal patch was not administered, then his blood pressure could increase and put him at risk of having a stroke. MA B stated she had not worked with Resident #1 since 03/07/2026.During a phone interview on 04/02/2026 at 11:53 AM, LVN D stated if a medication is not available for administration, then the policy is to check with the pharmacy to see how long it will take to deliver the medication if the medication is not in the emergency kit. She stated if the medication cannot be delivered in a timely manner, then the next step is to notify the provider and try to obtain an alternative order for something that is available. LVN D stated she was not informed that Resident #1 was out of his clonidine 0.3mg/24hr transdermal patches by any other staff members. LVN D stated she did not recall observing Resident #1's transdermal patches at all in March 2026. LVN D stated the clonidine patches are a slow release of medication to control blood pressure, so it could cause changes in the resident's blood pressure.During a phone interview on 04/02/2026 at 12:12 PM, LVN E stated that she had not been notified by any staff member that Resident #1's clonidine patches were unavailable. LVN E stated that Resident #1 mentioned missing his clonidine patch this past week and she found a box with Resident #1's patches in the unit 3 nurses medication cart and she moved it to the unit 3 medication cart. LVN E stated she remembered observing his patches in the nurses' medication cart earlier in March 2026 but is unsure exactly when.During an interview on 04/02/2026 at 12:42 PM, LVN A stated she was responsible for administering a clonidine 0.3mg/24hr patch to Resident #1 on 03/21/2026, but he did not have any available that day. She stated the 9 on the medication administration record was to indicate the medication was unavailable. LVN A stated she notified LVN D that day about the medication not being available and they both searched the unit 3 medication cart looking for the medication. LVN A stated she did not remember what the ordering status in the computer from the pharmacy was that day. LVN A stated if a resident were to miss their dose of clonidine patch, then it could affect the resident's blood pressure.During an interview on 04/02/2026 at 12:56 PM, the MD stated if a resident were to miss their clonidine 0.3mg/24hr patches for a month, then their blood pressure could go up. The MD stated he was not aware the medication had not been administered to Resident #1 for the month of March 2026, but he had reviewed Resident #1's medical record and his blood pressure had been stable with occasional spikes. The MD stated he talked with the NP about Resident #1's missing medication and was told she was notified by staff through text message.During an interview on 04/02/2026 at 03:11 PM, the DON stated the policy if a medication is not available is to get on the application for the pharmacy and notify the pharmacy that the medication is not available. She stated the pharmacy would then send the medication needed. The DON stated she would expect the medication aides to notify the charge nurse who would then notify herself about missing medications. The DON stated there was a Pyxis(a medication dispensing machine used for emergency medications) machine available to provide emergency medication that was unavailable. She stated the Pyxis had common medications that can be pulled and used in case the medication was out of stock. The DON stated she was not notified that Resident #1 was out of his clonidine 0.3mg/24hr patches by any staff members in March 2026. She stated if a resident missed this medication, then their blood pressure could increase.During an interview on 04/02/2026 at 04:00 PM, the ADM stated if a medication was not available, she expected the medication aide or person responsible for passing the medication to notify the charge nurse immediately. She stated if the charge nurse was unavailable at the time, then she would expect that staff member to contact the DON or the ADON. The ADM stated she would expect the charge nurse to search all the medication carts to ensure the medication is not in there. She stated if the medication could not be located then she expected the charge nurse to contact the pharmacy to get the medication in the building. She would also expect the charge nurse to notify the provider about the missed dose of medication and to attempt to obtain an alternative medication until the arrival of the missed medication. She stated she also expected to be notified of the missed medication. The ADM stated she was not notified Resident #1 has missed his clonidine 0.3mg/24hr patch for March 2026. She stated she is unaware of any outcomes due to the missed doses. The ADM stated she is not sure how missing the medication could affect a resident.Record review of the facility's policy titled, Administering Medications, dated 2001 and last revised April 2019, reflected: Policy headingMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.4. Medications are administered in accordance with prescriber orders, including any required time frame.6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform the process changes and or the need for additional staff training.21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents reviewed for grievances.The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance.Findings included:Review of the March 2026 grievance log revealed 17 grievances. The column titled Disposition of Grievance* revealed the nature of the grievance for each grievance. The column titled Date of Written Decision was left blank for each grievance. The March 2026 grievance log revealed * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved across the bottom of the log.Review of the March 2026 grievances revealed 10 of the 17 grievances did not have the section titled Findings of Investigation completed.During an interview and record review on 04/02/2026 at 01:15 PM, the ADON stated she had signed 12 of the 17 grievances for March 2026. She stated she had not been trained on how to complete a grievance or the process to follow when investigating a grievance. The ADON stated when a resident had a grievance that related to nursing, the SSD would give the grievance to either herself or the DON. She stated frequent in-services and re-education were administered to the nursing staff and sometimes it included 1:1 in-servicing with the staff involved in the grievance. The ADON stated the facility ensured the in-services were effective by performing angel rounds daily and making sure the resident was happy with the outcome. She stated there was not any record of the in-services or re-education performed in relation to the grievances. The ADON stated there were not any significant changes to the in-services from one grievance to another. She stated she was unsure if the residents were receiving written decisions related to the grievances they filed.During an interview and record review on 04/02/2026 at 02:14 PM, the SSD stated she was responsible for receiving, reviewing, and passing the grievances to the appropriate department in which the grievance is related to. She stated that after the appropriate department did their investigation, they returned the grievance form to her and she filed it. The SSD stated the person doing the investigation was responsible for completing the grievance form in relation to the investigation, outcome and notification. She stated she was not responsible for ensuring the form was completed correctly, the investigation was done thoroughly, or notification to the person who filed the grievance. She stated she was not sure if residents received written communication after the conclusion of the investigation related to their grievance. The SSD stated, we need to document better on our grievances and the education provided.During an interview on 04/02/2026 at 03:11 PM, the DON stated she had not recently read the policy related to grievances, but she had reviewed it in the past. She stated the department head in which the grievance related to was responsible for ensuring the grievance is completed correctly. She stated all the investigations related to each grievance were documented on their respective grievance forms. The DON stated there was not any other documentation anywhere else related to the education and in-services provided to staff related to grievances unless it is independently documented in the employee's human resources file. She stated the current process was to have the department head notify the person who filed the grievance verbally about the outcome of the investigation and to her knowledge there were no written responses sent to the person filing the grievance. She stated the ADM was updated on grievances and their investigation daily during the morning meeting.During an interview and record review on 04/02/2026 at 04:00 PM, the ADM stated she had not reviewed the grievance policy since the new company had taken over. The ADM was provided with a copy of the facility's grievance policy to review. The ADM reviewed the policy and stated, I don't feel like the policy is being followed 100% at this time. The ADM stated they were not providing the person who filed a grievance with a written follow up for the grievance they filed. The ADM was provided with all the grievances for March 2026. After the ADM reviewed the grievances, she stated she felt the policy was not being followed because there were blank spaces left on the grievances which indicated they were not completed. The ADM stated it could negatively impact resident by not completing grievances and providing written notification at the completion of a grievance by making the resident not feel comfortable with raising concerns, the resident may talk bad about the facility, or make the resident feel disgruntled, angry, or like they are not being heard.Record review of the facility's policy titled Grievances/Complaints, Filing, dated 2001 and last revised April 2017, revealed: Policy StatementResidents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman).The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.Policy Interpretation and Implementation.3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including a rationale for the response.8. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint.12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.a. The administrator, or his or her designee, will make such reports orally within ___[left blank] working days of the filing of the grievance or complaint with the facility.b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) to meet the needs of each resident for one of four residents (Resident #2) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #2's physician ordered medications Bisacodyl, lactobacillus, and polyethylene glycol prescribed for his Ogilvie syndrome. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs.Findings included:Review of Resident #2's face sheet dated 03/11/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Ogilvie syndrome (An intestinal pseudo-obstruction feels like something is physically blocking your bowels. But they aren't actually obstructed because they're paralyzed.), hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.), following a cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) Review of Resident #2's annual MDS assessment dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #2 was assessed to not have weight loss. Review of Resident #2's comprehensive care plan reflected a focus area dated 05/14/2025 I have an alteration in gastro-intestinal status related to recent DX of Ogilvie syndrome (pseudo obstruction). Interventions included, .Give medications as ordered. Monitor/document side effects and effectiveness. Review of Resident #2's consolidated physician orders reflected the following orders: Bisacodyl rectal suppository 10 mg one time a day for constipation dated 06/20/2025, lactobacillus give two tablets by mouth one time a day dated 01/11/2026, and Polyethylene Glycol 17 grams by mouth two times day dated 07/16/2025. Observation and interview with Resident #2 on 03/11/2026 at 10:00 AM revealed Resident #2 in his room up in his wheelchair. Resident #2 stated he was not getting his medications for his constipation consistently. He stated they told him they changed pharmacies, but he has run out of medications and he needs them. He stated last night he did not get his suppository. He stated they told him they ran out of them. Review of Resident #2's MAR for March 2026 reflected he did not receive his lactobacillus on 03/01/2026 through 03/04/2026. Further review reflected Resident #2 did not receive his polyethylene glycol on 03/03/2026 or 03/04/2026 and did not receive his bisacodyl suppository on 03/10/2026. Review of Resident #2's nursing progress notes from 03/01/2026 through 03/04/2026 reflected the reason for the lactobacillus not being administered was it was on order. Further review reflected on 03/03/2026 and 03/04/2026 that his polyethylene glycol was not administered due to being on order. Review of his nursing note dated 03/10/2026 reflected his bisacodyl suppository was not administered due to being on reorder. In an interview on 03/11/2026 at 11:04 AM Resident #2's RP stated it has been an ongoing problem with Resident #2 running out of his medication and he was out for multiple days. He had not received his lactobacillus, polyethylene glycol and bisacodyl suppository for multiple doses. She stated he had Ogilvie syndrome (caused by his stroke) (unexplained paralysis of his colon) and he has to have these medications to keep his bowels moving. She stated he has not had any problems yet but did not want him to have any. In an interview on 03/11/2026 at 11:30 AM MA B stated Resident #2's medications polyethylene glycol, and probiotic are over the counter. She stated they have to have their order for OTC medications to the DON on Monday and they receive the medications on Wednesday. MA B stated if they miss the order on Monday then they have to wait until the next week to put in another order. In an interview on 03/11/2026 at 11:52 AM Resident #2's NP stated she expected all residents to get their ordered medications, and it is very important to have consistency in his medication administration. She stated she expected the facility to have all medication on hand for administration. In an interview on 03/11/2026 at 11:56 AM the DON stated the facility ordered OTCs a week ahead of time and stated they did have a contract with a local pharmacy and the facility could get OTCs from there. The DON stated the facility should not be running low on OTC medications and no one should run out of medications. She stated after looking at her order list on her desk that Resident #2's suppositories were not on the list for this week's delivery, but she would make sure it was ordered. In an interview on 03/11/2026 at 2:05 PM the Administrator stated resident medications should always be available and if not, someone should go get them if they are out. The Administrator stated medications should never be missed. Review of the facility's policy Medication Orders and reorder (not dated) reflected The facility shall maintain accurate documentation of all medications ordered, reordered, dispensed, and received. Medication ordering and receipt processes will be managed through the facility's electronic health record (EHR) and coordinated with the contracted dispensing pharmacy. Emergency or STAT medications may be obtained through emergency drug kits. STAT pharmacy delivery, or provider STAT orders entered in EHR. Emergency medications must still be entered into EHR and documented on the Electronic MAR. Review of the facility's policy Administering Medication dated 04/2019 reflected Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for one of four residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to protect Resident #1 from CNA A, who at some point during her employment from 10/30/2025 through 12/09/2025 took Resident #1's debit card and incurred at least 36 unauthorized charges from 11/29/2025 through 02/08/2026. This failure placed residents at risk of misappropriation of property and financial loss. Findings included: Review of Resident #1's face sheet dated 11/10/2025 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Diabetes Mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), and hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1 was assessed to have a BIMS score of six indicating she had severe cognitive impairment. Resident #1 was assessed to require partial to substantial assistance with all ADLs. Review of Resident #1's comprehensive care plan reflected a focus area dated 11/21/2025 Impaired coping. Interventions included Encourage times of rest and relaxation between care activities. Include Resident/ Representative in determining next steps in care. Review of the facility's provider investigation report dated 03/03/2026 reflected the facility was made aware on 03/02/2026 that staff CNA A had been arrested and was being held for credit card or debit card abuse of the elderly for the allegation of taking Resident #1's debit card and using it in the area for personal purchases. Review of a statement provided by law enforcement dated 03/03/2026 reflected .[CNA A] is alleged to have committed financial exploitation of the Resident from 11/29/2025 through 02/08/2026. The Resident incurred at least 36 unauthorized charges on her credit card. The transactions occurred in multiple cites.The card was used at liquor stores, grocery stores, and gas stations (unsure of the dollar amount associated with the charges as the matter remains under investigation by law enforcement.) The CNA was employed by the facility beginning in November 2025 and her last day of employment was 12/09/2025. On 03/03/2026 the CNA was arrested and is currently being held on charges of credit card abuse of an elderly individual. The Residents family member who is his power of attorney, reported the matter to law enforcement. The [family member] stated it was in the best interest of the resident not to be informed of the situation due to her stress and related mental health concerns. Observation and interview on 03/11/2026 at 10:10 am revealed Resident #1 in her room alert. She did not have any complaints regarding staff treatment and did not voice any concerns regarding any missing personal items. In an interview on 03/11/2026 at 11:23 AM Resident #1's RP stated that while he was checking Resident #1's debit card statement that he noticed a lot of charges to her card that she could not have made. He stated that he called the police and reported it. He stated he did not tell the facility about the charges because the police told him not to tell them until more investigation was performed to ensure she was the only one in on it. He stated the facility could not have known about it because the card statements are sent to him. He stated the detective has the CNA in custody stating they had her on video in a store using Resident #1's debit card. He stated the facility was notified after the CNA was apprehended and they were told not to tell Resident #1 because he did not want her to worry since there was nothing she could do about it. Review of CNA A's employee record provided by the facility on 03/11/2026 reflected she was hired on 10/30/2025 and her last day worked was 12/09/2025. She was terminated on 12/12/2025 for no call no show. Further review of her employee record reflected her criminal history check was performed on 10/29/2025 which did not reveal any offence that would hinder her employment. In an interview on 03/11/2026 at 1:50 PM the DON stated CNA A started work at the facility on 10/30/2025 and stated her last day was 12/9/2025. She stated she was terminated for not showing up to work. She stated she had not had any complaints about her while she was working at the facility. In an interview on 03/11/2026 at 2:05 PM the Administrator stated that the facility did not receive the credit card statements for Resident #1 and she was unaware of any misappropriation for Resident #1 until she received a subpoena from the detective. She stated at that point she reported the misappropriation to HHSC. Review of the Subpoena Deuces [NAME] dated 03/02/2026 reflected a summons for the facility to appear in court to provide all records pertaining to the employment and termination of CNA A. The subpoena was signed by the detective. Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation and Prevention Program dated April 2021 reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. 2. Develop and implement policies and protocols to prevent and identify: c. theft, exploitation or misappropriation of resident property. 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has; a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c. a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on observation, interview and record review the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for one of four residents (Resident #2) reviewed for physician ordered supplements. The failed to ensure Resident #2 received his physician ordered supplement ensure clear with his lunch meal. This failure placed residents at risk for weight loss, malnutrition, and poor quality of life.Findings included: Review of Resident #2's face sheet dated 03/11/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Ogilvie syndrome (An intestinal pseudo-obstruction feels like something is physically blocking your bowels. But they aren't actually obstructed because they're paralyzed.), hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) following a cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) Review of Resident #2's annual MDS assessment dated [DATE] reflected Resident #2 was assessed to have a BIMS score of 13 indicating he was cognitively intact. Resident #2 was assessed to not have weight loss. Review of Resident #2's comprehensive care plan reflected a focus area dated 10/21/2025 State of nourishment, less than body requirement characterized by weight Loss, inadequate intake, decreased appetite related to: Cognitive Impairment, Decreased Appetite. Interventions included .Provide therapeutic supplements. Review of Resident #2's consolidated physician orders reflected an order dated 05/27/2025 ensure clear with noon/lunch meal one time daily. Review of Resident #2's weight record from 10/08/2025 through 03/03/2026 reflected he had not had significant weight loss. His 10/08/2025 weight was recorded at 164.8 and his 03/03/2026 weight was recorded at 164.6. Observation and interview on 03/11/2026 at 10:00 am revealed Resident #2 was up in his wheelchair in his room. Resident #2 stated he did not like the food at the facility. He stated he was supposed to be getting a supplement at lunch, but they never gave it to him. In an interview on 03/11/2026 at 11:04 AM Resident #2's RP stated Resident #2 was not getting his ensure clear as ordered. She stated she has asked the facility at the past two care plan meetings to make sure he was getting his supplement, but nothing has been done. Observation on 03/11/2026 at 1:20 PM revealed Resident #2 in his room with his lunch tray. No supplement was observed on his tray. In a follow-up interview on 03/11/2026 at 2:00PM Resident #2's RP stated she had told the facility at the last two care plan meetings with the last one being in October 2025. She stated at the meeting she told the social worker about Resident #2 not getting his ensure clear. Review of Resident #2's care plan meeting dated 10/07/2025 reflected under section problem/needs needs clear ensure. In an interview on 03/11/2026 at 1:50 PM the DON stated she was not aware Resident #2 was not getting his ensure clear. She stated the facility can order the supplement and there was no reason he should not be getting the supplement. She stated if a resident had an order for a supplement she expected them to get it. In an interview on 03/11/2026 at 2:17 PM the SW stated she remembered Resident #2's family telling her about the ensure clear. She stated she thought she passed that on to nursing. She stated she was responsible and should have followed up to make sure he was getting it. Requested policy for physician ordered supplements on 03/11/2026 at 2:50 PM. Policy sent at 3:17 PM was Administering Medication dated 04/2019 which reflected Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview and record review the facility failed to ensure storage of drugs and biologicals used in the facility for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure medications were stored and used in an orderly manner to ensure the liquid did not run down the sides of the bottle causing it to be sticky on the sides of the bottle and the bottle was stuck to the bottom of the medication cart drawer. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications. Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of lactulose in the medication cart drawer which was sticky on the sides of the bottle and the bottle was stuck to bottom of cart. In an interview on 09/04/2025 at 2:35 pm, LVN A stated the lactulose bottle was sticky and should have been cleaned. In an interview on 09/04/2025 at 3:00 PM the DON stated that staff should check the medication prior to administration to ensure the medications are stored properly. Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #2) reviewed for parenteral fluids The facility failed to ensure Resident #2's PICC line dressing was changed per physician orders. This failure could place residents with PICC line dressing at risk for potential infections.Findings included: Review of Resident #2's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Staphylococcal arthritis, left knee, (infection of knee joint) sepsis (occurs when your immune system has a dangerous reaction to an infection) and methicillin susceptible staphylococcus aureus infection. Review of Resident #2's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to have the administration of IV medications. Review of Resident #2's comprehensive care plan reflected a focus area dated 08/15/2025 for Resident is receiving intravenous (IV) medication for acute treatment. Interventions included .monitor IV site every shift for signs of infiltration (leaking into the skin) . Review of Resident #2's consolidated physician orders dated 09/04/2025 reflected an order dated 08/15/2025 to change PICC line dressing every week and PRN. Review of Resident #2's TAR dated 08/2025 reflected an entry to change Resident #2's PICC line dressing every week. The dressing change was due 08/31/2025 and it was signed off as done by LVN B. Observation and interview on 09/04/2025 at 2:00 pm revealed Resident #2 in room in bed. Observation of PICC line dressing revealed it was dated 08/24/2025, with no signs of infection. Resident #2 stated the site did not hurt, and she stated she did not know when the dressing was changed last. In an interview on 09/04/2025 at 3:30 PM the DON stated after review of Resident #2's TAR that Resident #2's PICC line dressing change was signed off as completed on 08/31/2025 by LVN B. The DON stated LVN B obviously did not change the dressing if the dressing was dated 08/24/2025. The DON stated it was not appropriate to sign off on doing a treatment and not completing the task and it was her expectation that PICC line dressing be changed per MD orders to prevent infections. The DON provided LVN B's phone number and stated she would probably not answer because she was out of the country. Attempt to contact LVN B on 09/04/2025 at 3:45 PM revealed no answer and no voicemail on phone number provided. Review of the facility policy peripheral and midline IV dressing change dated 03/2022 reflected This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised Maintain sterile dressing (transparent semi-permeable membrane dressing or sterile gauze) for all peripheral catheter sites. Change the dressing if it becomes damp, loosened or visibly soiled and: at least every 7 days.

Based on observation, interview and record review the facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure on 09/04/2025 that expired medications (one bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025) were removed from the station one medication cart once expired. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications.Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025. In an interview on 09/04/2025 at 2:35 pm, LVN A stated it was the medication aide's responsibility to ensure expired medication are not on the cart, but they currently did not have one and since he was passing medications on the cart it was his responsibility to ensure the expired drugs were removed to ensure the residents do not get expired medications which could be less effective. In an interview on 09/04/2025 at 3:00 PM the DON stated both medications were expired and were removed from the medication carts. The DON stated the staff should check the medication prior to administration to ensure the medications are not expired. Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 3 residents (Resident #1) reviewed unnecessary drugs. The facility failed to ensure PT/INR laboratory tests (to measure blood clotting time and thus ensure safe blood levels of the anticoagulant, warfarin) were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death.Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference range for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was not in discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects, and the surveyor may not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalUnnecessary Drugs, F-757 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1 (R1) was assessed upon return from the hospital following diagnosis of Coumadin (Warfarin) overdose. Physician was notified, and R1's Warfarin order was discontinued. PT/INR monitoring updated to reflect daily labs per new order.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: R1's care plan updated to include risk for medication-related adverse effects, monitoring for bleeding/bruising, and ongoing INR surveillance.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: Action: Conducted audit of all residents receiving anticoagulants (e.g., Warfarin) to review appropriateness of medication, frequency of PT/INR monitoring, and compliance with physician orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 11PM Action: Reviewed pharmacy consultant reports and prior medication regimen reviews to ensure unnecessary medications were not continued without indication.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 by 12PM Action: The Director of Nursing and the Assistant Director of Nursing will utilize the Clinical Meeting form (includes section for laboratory and diagnostic studies) to list all laboratory studies that were to be drawn that day. The Director of Nursing and the Assistant Director of Nursing will put a check next to the laboratory study once the test is resulted. The Director of Nursing and the Assistant Director of Nursing will then validate that the MAR/TAR reflect accurate documentation that the laboratory study was collected. 3. Measures Put into Place/System Changes to Remove the Immediacy Action: The Director of Nurses was educated on the Side Effects of High-Risk Medications and recognition of adverse effects and High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy. The Director of Nursing will validate understanding of the training material by summarizing the information she was educated on. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 by 7PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on Side Effects of High-Risk Medications and recognition of adverse effects prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 - 7/10/2025 by 12 noon Action: Facility policies on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy reviewed by VP of Clinical Operations with no changes identified. All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated on High-Risk Medications-Anticoagulant Policy and Laboratory Services and Reporting Policy prior to working their next shift. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All staff educated will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/10/2025 Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F757, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at

Based on observation, interview and record review the facility failed to ensure laboratory services were provided or obtained to meet the needs of its residents for 1 of 3 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure PT/INR laboratory tests were obtained weekly as ordered for Resident #1 on 04/14/25, 04/28/25, 05/05/25, 05/12/25, 05/26/25, 06/09/25, 06/16/25 and 06/30/25. Resident #1 was presented with multiple, unexplained bruising to her face, tongue, and extremities on 07/05/25 and was hospitalized for a warfarin overdose on 07/07/25. An Immediate Jeopardy (IJ) was identified on 07/09/25. While the IJ was removed on 07/11/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse effects from high-risk medication such as bruising, uncontrolled bleeding, and death. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included chronic atrial fibrillation (irregular heartbeat), congestive heart failure (long term condition in which the heart cannot pump blood well enough to meet the body's needs), chronic respiratory failure with hypoxia (breathing problems with low blood oxygen), chronic obstructive pulmonary disease (chronic breathing disorder), asthma, hypertension (high blood pressure), major depressive disorder, unsteadiness on feet, abnormalities of gait and mobility, dementia, fibromyalgia (long-term condition that involves widespread body pain), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, dependence on supplemental oxygen, obstructive sleep apnea (sleep-related breathing disorder), anxiety disorder, cochlear implant (electronic hearing device that provides a sense of sound to people with severe hearing loss) status, chronic migraine (headache), and mild cognitive impairment of uncertain or unknown etiology (origin). Record review of Resident #1's annual MDS reflected a BIMS score of 15, which indicated intact cognition. Resident #1 received anticoagulant medication during the 7-day lookback period. Record review of Resident #1's care plan, dated 01/10/25, reflected the following: The resident is on Anticoagulant therapy r/t A-fib. The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Daily skin inspection. Report abnormalities to the nurse. Labs as ordered. Report abnormal lab results to the MD. Monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, , diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, Loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Resident/family/caregiver teaching to include the following: Take/give medication at the same time each day, Use soft toothbrush, Use electric razor, Avoid activities that could result in injury, Take precautions to avoid falls, Signs/symptoms of bleeding, Avoid foods high in Vitamin K. These include greens such as spinach and turnips, asparagus, broccoli, cabbage, Brussels sprouts, milk and cheese. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Record review of physician orders for Resident #1 reflected the following:-Warfarin Sodium oral tablet 4 mg- take 2 tablets one time per day for chronic atrial fibrillation start date 03/18/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use send lab order Sunday start date 06/22/25-PT/INR on Mondays- one time a day every Monday due to anticoagulant use start date 09/30/24 end date 06/21/25-Side effects to anti-coagulant medication 1) Discolored urine 2) black tarry stools 3) muscle/joint pain 5) lethargy 6) increased bruising 7) sudden changes in mental status/vitals 8) shortness of breath 9) nosebleeds. Every shift for preventative measure if side effects were noted, documentation and physician notification were required.-Diphenhydramine HCl 25 mg Benadryl, one time administration 07/07/25 Record review of Resident #1's MAR/TAR from April 2025 to July 2025 reflected the following dates were marked as complete for PT/INR04/14/25 (no corresponding laboratory test)04/28/25 (no corresponding laboratory test)05/05/25 (no corresponding laboratory test)05/12/25 (no corresponding laboratory test)05/19/25 (correlating lab test on 05/20/25)06/02/25 06/09/25 (no corresponding laboratory test)06/16/25 (no corresponding laboratory test)06/23/2506/30/25 (no corresponding laboratory test, documented by LVN K)The following dates were not marked as complete for PT/INR:04/07/2504/21/25 Record review of PT/INR results for Resident #1 reflected the following:04/07/25 PT 23.3 and INR 2.104/21/25 PT 34.5 and INR 3.405/20/25 PT 28.1 and INR 2.606/02/25 PT 35 and INR 3.506/23/25 PT 30 and INR 2.8(Note: A normal INR range for people who take warfarin is 2-3 but can vary from patient to patient. Patients who tend to clot more easily may have an INR target range of 3-4.) Review of pharmacy consultant reports for Resident #1 from January 2025 to July 2025 reflected her drug regimen was reviewed by the consultant pharmacist each month, and no recommendations were made related to her drug regimen. Record review of Resident #1's nursing progress notes reflected the following:07/05/25 at 06:15 PM, written by LVN B, resident states she has been complaining of discomfort to Left lower leg, states when she went to the restroom she noticed a dark red/purple bruise. Resident states she did not hit or bump it while transferring states where the bruise is where she had been hurting all week. Notified NP of findings no new orders at this time.07/06/25 at 02:04 PM, written by LVN E notified by family that resident had bruising on her face, left dorsal hand, thumb, wrist, LLE both front and back. Resident does not remember falling. She states I'm always in this chair. Residents VS are with in normal limits, speaks normally, but says it hurts to open her mouth and her leg hurts. Leg has some swelling refused ice pack.07/06/25 at 02:14 PM, written by LVN E resident took Tylenol with no issues07/06/25 at 05:06 PM, written by LVN E PT/INR in the morning NP checked on resident. Coumadin on hold. No Xray or hospital visit was needed at this time.07/07/25 at 01:56 AM, written by RN A Resident complained of glossitis (inflammation and swelling of the tongue). Purplish bruising on right side of tongue. Bruising also noted to left chin area, left hand, left lower posterior leg. Resident denies falling. No history recent falls noted. Vitals stable 120/69, P62, RR20, O2-94%-2L with dyspnea[shortness of breath]. EMS in route. MD, family, DON notified. Called report to ER.07/07/25 at 02:27 AM, written by RN A Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth one time only for Skin Irritation for 1 Day route. MD, family, DON notified. Called report to ER.07/07/25 at 04:28 AM, written by LVN D RN called from [hospital] to ask how long we had held the resident's coumadin. Writer answered all her questions. She informed writer that the patient was receiving a dose of IV Vitamin K as we spoke and if the head CT came back negative she will be discharged . [RN] also provided me with patient's lab results. PTT: 158.9 RANGE: 22.9-36.1INR: 12.6 RANGE: CRITICAL IS GREATER THAN 6PT:96 RANGE: 12-14.707/07/25 at 10:04 AM, written by the DON Resident assessed by nurse, this nurse spoke with resident, resident denies fall, denies feeling ill, denies headache, denies SOB. Resident states her tongue is bigger than her mouth but has gotten smaller she thinks. Resident was observed drinking her coffee without difficulty stated by resident. Resident informed we would like to send her to the hospital for monitoring, resident stated she did not want to go that they won't do nothing for her. NP notified, hospital called spoke with ER nurse, she stated that her tongue was swollen while she was there, she received Vit K, and discharged back to[the facility]. PT/INR ordered for daily, Coumadin held and removed from medication cart and placed in medication room unit 4.07/07/25 at 04:35 PM, written by LVN F Warfarin Sodium Oral Tablet 4 MG, Give 2 tablet by mouth one time a day related to Chronic Atrial Fibrillation, Unspecified (I48.20) med on hold07/07/25 at 04:43 PM, written by LVN F Res has been without c/o pain/discomfort, SOB, dizziness, headache since return from ER. Drank 2 bowls of tomato soup and drank glass of tea for lunch without incident/difficulty. Res cont. to state she feels as if her tongue swelling is going down. Sitting up in [sic] recliner chair in room per usual routine. Will cont. to monitor closely for changes in condition.07/08/25 at 11:44 AM, written by RN B Patient is on bleeding precautions related to anticoagulant therapy. Daily PT/INR to monitor levels. Coumadin on hold. Patient noted to have bruising to left chin, left hand, bilateral ankles, scattered bruising on trunk, and tongue. Swelling to tongue has subsided, no issues with swallowing/eating/breathing. Patient denies any pain. VSS. 143/83 87 97.8 18 93% on RA. Record review of hospital records for Resident #1, dated 07/07/25, reflected the following: Communications: critical lab value, received at 0327 [03:27 AM], received from lab, critical results: INR 12.6/PTT158. Triage notes: from (facility); diffuse bruises. Tongue bruising/swelling. Bruise to left hand. Bruise to left jaw. Dried blood behind right ear. Bruising to left foot. Denies injury. Does not remember falling. Doctor Notes: This is a 91 Y/O F with a PMHx of dementia, afib, HTN, polyosteoarthritis, osteoporosis, urinary incontinence, HLD, COPD, asthma, abd sx, and GERD presenting to the ED via EMS from NH with a CC/O multiple bruises throughout the body. EMS reports BP of 122/83 and SP02 of 95%. EMS does not know the etiology beyond her bruises, falling, tripping, or any other trauma related injury. Diagnosis final: primary: overdose - Coumadin warfarin, additional: Ecchymosis [flat area of discolored skin], elevated INR. During observation and an interview on 07/09/25 at 07:30 AM, Resident #1 was sitting in her recliner chair having breakfast. She had a very dark bruise stretching across her left cheek and jaw and one on the wrist and thumb of her left hand. She stated, I'm doing better than I look. She said the bruises just showed up on her because she had too much blood thinner. She said she went to the hospital for two days and that was what the hospital told her. She said the bruises did not hurt anymore, though the ones on her legs did hurt at first. She lifted her pants leg and had more bruising on her left, lower leg. An attempted interview with RN A was made on 07/09/25 at 08:10 AM to by telephone. A voicemail was left. An attempted interview with LVN C was made on 07/09/25 at 08:11 AM to by telephone. The outgoing message stated the wireless customer you are trying to reach is not available. Please try again later. A second attempt was made on 07/11/25 at 09:00 AM. During an interview on 07/09/25 at 08:30 AM, LVN D stated she worked the night Resident #1 was sent to the hospital. She stated the nurses on that shift decided together to send Resident #1 to the hospital. She stated the nursing team knew Resident #1 was on Warfarin, and when they came in, Resident #1 was covered in bruises, her tongue was really swollen, and she had difficulty breathing. LVN D stated she had checked the PT/INR results and discovered that the lab test had not been done as ordered since 06/23/25. She stated they had no idea whether Resident #1 had safe levels of warfarin, and she stated she looked up the swollen and bruised tongue and saw online that it could be a symptom of warfarin overdose. The charge nurse on Resident #1's hall, LVN C, administered Benadryl (diphenhydramine HCl) thinking it might have been an allergic reaction, but the Benadryl did not help. She said Resident #1 could barely talk. LVN D stated she took some pictures of the bruising and swollen tongue for the DON. She stated they tried to find information on the shift change report, but there was nothing definite- only to hold the warfarin. LVN D stated there was an order for a PT/INR to be done the following day (Monday 07/07/25) but the lab requisition had not been completed. LVN D stated the nurses decided to call EMS and send Resident #1 out. She said she got a call from the nurse at the ER about 04:00 AM that morning (07/07/25) letting them know Resident #1's PTT was over 150 and her INR was 12.6. LVN D stated those levels were very elevated. She stated the normal reference rage for someone not on warfarin was around 2 or 3. She stated the hospital RN told them Resident #1 received an infusion of vitamin K to bring the levels down. A telephone interview was attempted on 07/09/25 at 11:59 AM with LVN B (was charge nurse for administered Benadryl to Resident #1 on 07/07/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 12:05 PM, the DON stated LVN E was in the facility working and a request was made for an interview. The DON stated LVN E was at an appointment. LVN E did not present herself for an interview. A telephone interview was attempted on 07/10/25 at 10:03 AM and a voicemail was left, but there was no response as of 07/12/25. The DON was asked why Resident #1's PT/INR levels were not checked weekly as ordered, and she did not answer. i A telephone interview was attempted on 07/09/25 at 12:12 PM with LVN K (documented a PT/INR on Resident #1's MAR on 06/30/25). A voicemail was left and not returned prior to 07/12/25. During an interview on 07/09/25 at 02:53 PM, the NP stated she received a call from LVN E on Sunday 07/06/25 notifying her Resident #1 had unexplained bruising. The NP said she came to the facility, saw the bruising, and knew right away it was a reaction to the warfarin. She stated the bruises were small, they were not hardened, and Resident #1 stated she was in not discomfort. The NP stated she felt there was no need for emergent care, ordered a hold on the warfarin, and ordered a PT/INR to be taken the following day. She stated she was not aware Resident #1 had gone to the hospital and had not seen the results of the hospital PT/INR test. She amended her statement to say she was aware Resident #1 had gone to the hospital, but she was not aware of the results of the hospital visit. She stated the bruises looked much worse today than they had on 07/06/25. She stated the PT/INR tests should have been performed as ordered, but it was a fluke that her PT/INR values had gone up so much and so quickly. She laughed and said they could not have known there would be high PT/INR levels and the bruising and high PT/INR levels were not adverse effects and the surveyor did not know what adverse effects meant. When asked if the increase in lab values might have been detected sooner if the PT/INR test was run on 06/30/25 as ordered, she did not answer verbally but shrugged and nodded her head yes. During an interview on 07/09/25 at 03:02 PM, the MD stated Resident #1 was on the same dose of warfarin since 03/18/25, which meant her PT/INR was stable. He stated the standard of practice was to test for PT/INR once per month in a stable patient on warfarin. He stated the goal INR for Resident #1 was 2-4. The MD stated if the PT/INR was ordered once per week, it should have been done once per week. He stated he was not notified of Resident #1 going to the ER with bruising and a swollen tongue or of her critically high PT/INR levels. He stated Resident #1 had an adverse reaction, but he still thought monthly was frequently enough to check PT/INR levels. During an interview on 07/09/25 at 04:02 PM, the DON stated prior to the investigation entrance, she had not received any hospital documentation for Resident #1 and was not aware of what had occurred. She stated she was aware Resident #1 went to the hospital, but she did not know the outcome. She stated her expectation was all orders were followed. She stated she did not know why the PT/INRs were not done as ordered for Resident #1 and she did not know why they were documented as done. She stated she did not know who was responsible for making sure the labs were done, and the side effect monitoring was completed for high-risk medications. She stated she guessed it was her job. She did not answer any more questions. Record review of the National Library of Medicine's website, accessed on 07/11/25, at the web address medlineplus.gov/lab-tests/prothrombin-time-test-and-inr-ptinr reflected the following definition for PT/INR: PT/INR is a blood test that measures how long it takes for a clot to form in a blood sample. PT stands for prothrombin time, which is a protein made by the liver and one of the clotting factors. INR stands for internationalized normalized ratio, which is a calculation based on PT test results. PT/INR test can be used to check for bleeding problems or to monitor the effect of medicine to prevent blood clots. Record review of an article titled Practical tips for warfarin dosing and monitoring, accessed on 07/11/25, at the web address www.ccjm.org /content/ccjom/70/4/361.full.pdf reflected the following: PATIENTS WHO TAKE WARFARIN (Coumadin) walk a tightrope between bleeding and clotting- and a hundred things can tip the balance. It's a difficult drug to use, with a narrow therapeutic index, but 60 years after it was introduced it is still the mainstay of oral anticoagulant treatment . The INR was developed in 1982 by the World Health Organization's Expert Committee on Biologic Standardization in response to variations in thromboplastin sensitivity and different ways of reporting the prothrombin time across the world.8 Inappropriate management can lead to subtherapeutic or supratherapeutic INR values, increasing the risk of acute or recurrent thromboembolic episodes or bleeding episodes, respectively. For most indications, the therapeutic INR range is 2.0 to 3.0. Exceptions are when warfarin is used for secondary prevention after a myocardial infarction or for patients with high-risk mechanical prosthetic heart valves, in which case the range is 2.5 to 3.5. Record review of an article, accessed on 07/11/25, at the web address my.clevelandclinic.com/health/diagnostics/prothrombin-time-test reflected the following: Labs measure prothrombin time in seconds based on how long it takes your blood to clot, or (more commonly) as the International Normalized Ratio (INR). The World Health Organization (WHO) developed the INR as a standardized measurement that accounts for differences in lab testing processes.The normal ranges for PT/INR results are:11 to 13.5 seconds.INR of 0.8 to 1.1.INR of 2.0 to 3.0 if you're taking warfarin. (There are some conditions for which a higher or lower target PT range is desired.). Record review of the facility's, undated, policy titled Laboratory Services and Reporting reflected the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law.Policy explanation and compliance guidelines:The facility must provide or obtain laboratory services to meet the needs of its residents.The facility is responsible for the timeliness of the services. Record review of the facility's, undated, policy titled High Risk Medications- Anticoagulants reflected the following: Policy: this facility recognizes that some medications, including anticoagulant, are associated with greater risks of adverse consequences than other medications. This policy addresses the facilities collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety.Policy explanation and compliance guidelines:Anticoagulant shall be prescribed by a physician, authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke, or management of myocardial infarction.Target symptoms, (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulant shall be documented in the residence medical record. Duration of use shall be appropriate to the resident's condition and indication for use.Routine labs, including baseline, and subsequent labs, shall be ordered for each resident requiring anticoagulant medication. Results shall be communicated to the physician in a timely manner. This was determined to be an Immediate Jeopardy (IJ) on 07/09/25 at 5:30 PM. The ADM and DON were notified. The ADM and DON were provided with the IJ template on 07/09/25 at 05:30 PM.During an interview on 07/29/25 at 01:46 PM, RN A stated she had left employment at the facility in mid-July 2025. She stated the procedure for intervention in a change of condition or a medical emergency was to call the NP, and if there was no answer to call the MD. She stated if there was still no answer, they were to call the NP hotline for an on-call nurse practitioner. RN A stated she spoke to the NP about sending Resident #1 to the hospital on the night of 07/07/25, so she did not need to call the MD. RN A stated that night she relied on LVN D to help her through the process, because she was new at the facility and did not know the residents as well. RN A stated what was in her progress note about that night was what was done. She stated she did not want to answer more questions.During an interview on 07/29/25 at 02:14 PM, the PHARM stated she was not aware of any problems with Resident #1's drug regimen or with the warfarin side effects that sent Resident #1 to the ER. She stated she reviewed Resident #1's meds in May/June but made no nursing or physician recommendations for follow up on PT/INR. She stated she typically looked for labs done at least monthly and Resident #1 had not had any issues with results or not getting the labs done at least monthly. During an interview on 07/29/25 at 02:42 PM, a laboratory technician stated they had an outreach group that went to the facility and picked up the requisitions in the lab books and then noted in the lab book after lab draws were completed. She stated her supervisor would be able to access details about all the other labs that had been drawn for Resident #1. She stated her supervisor was not available and took a message, which was not returned as of 08/04/25.The following Plan of Removal submitted by the facility was accepted on 07/10/25 at 04:04 PM: Plan of RemovalLaboratory Services, F-770 1. On 7/9/2025, an abbreviated survey was initiated at the facility. On 7/9/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Action: Resident #1's (R1) care plan was immediately updated to reflect enhanced monitoring for signs/symptoms of bleeding, adherence to anticoagulant lab schedules, and dietary precautions. All current lab orders were reviewed, and a daily PT/INR was obtained.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM 2. How the Facility Identified Other Possibly Affected Residents: Action: An audit of all residents receiving anticoagulant therapy (including Warfarin) was completed. Orders were reviewed to ensure that laboratory monitoring, including PT/INR, was in place and being followed. Any discrepancies were corrected immediately. No other residents were identified to have missed required labs.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 8 PM 3. Measures Put into Place/System Changes to Remove the Immediacy Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified, the physician will be notified, and the facility will follow orders. No other laboratory studies were missed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PMAction: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by VP of Clinical Operations and Sr. VP of Operations and no changes are identified as needed at this time.Person(s) Responsible: VP of Clinical Operations and Sr. VP of OperationsDate/Time: 7/9/2025 by 10PM Action: All licensed nursing staff, all new staff that are currently in the onboarding process, agency nurses who are scheduled to work in the facility, and all PRN nurses were re-educated over reviewing scheduled laboratory tests and validating that the lab requisition is completed and placed in the laboratory binder at each of the nursing stations. If the laboratory requisition is not located in the laboratory binder the Charge Nurse is responsible for completing the laboratory requisition immediately and notifying the Director of Nurses. Any new hires, agency nurses and new PRN nurses will be educated prior to working their first shift in the facility. All educated staff will be required to verbalize in his/her own words what they learned from the education provided. This will allow for re-education and clarification at that moment and facilitate re-education immediately.Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 11PM Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing all scheduled clinical labs in daily clinical meeting, Monday thru Friday, to ensure labs that were ordered have been drawn and that results for labs have been received prior to leaving their scheduled shift, that appropriate lab communication to the MD and/or their extender have occurred when labs have been received, and any labs that were scheduled and not drawn will be drawn by the Director of Nursing or the Assistant Director of Nursing immediately and transported to the laboratoryPerson(s) Responsible: Regional Clinical Support Nurse ConsultantDate/Time: 7/9/2025 @ 11PM Action: QAPI meeting held with the Medical Director to discuss the Immediate Jeopardy template, F770, and the facility's plan of action to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date/Time: 7/9/2025 by 11PM Monitoring of the POR included the following: During an interview on 07/11/25 at 09:56 AM, the RNC stated she in-serviced the ADON and the DON on high-risk medications, lab services, nurse staff daily posting and quality of care. She said the DON and ADON conducted all the in-services for the nurses. She stated an example of high risk medications was anticoagulants which were important to monitor. She stated they should be doing the PT/INR every Monday without fail and do side effects monitoring every day every shift for adverse effects, example bruising, swelling of the tongue. She stated they made sure they are checking each shift for bruising or any complaints of difficulty swallowing. She stated staff was instructed to monitor the resident's diet, educated on how other medications can interfere with high-risk medications. The RNC stated she reviewed the facility policy that spoke about anticoagulants and monitoring for the main side effects of bruising to ensure it was thorough, and it was. She stated it was important that they do the PT/INRs scheduled as ordered because that showed if the resident had a safe level of anticoagulant in her system. She stated the process for lab services was when they received the order it was placed in the lab tracker/binder along with a requisition. She stated they then waited for results, and if any were missed they followed up with the lab. She stated the requirement for the DON and ADON was to print out the labs from the EMR that were ordered for the day and before they went home to make sure labs had been completed as ordered or find out why they had not. She stated they had conducted in-services on weekly labs for warfarin users unless ordered sooner by the NP/MD. She stated the lab tech who drew the labs needed to be contacted if the labs were not signed off. She stated the lab binder should remain at each nurse's station and when nurses received an order, they were to fill out the requisition and place it in the book. She stated staff were required to give residents the basic standard of care they deserved and needed. During an interview on 07/11/25 at 08:30 AM, LVN D stated she worked 6 AM-6 PM. She stated she felt like she already was pretty comfortable with the procedure. She stated it was just a matter of it getting done. She stated they needed to be conducting the PT/INR labs weekly. PT/INR results for anybody who's on strong anticoagulant needed to be checked. She stated they needed to check PT/INR results anytime they administered an anticoagulant. She stated she really did not administer on her shift, but she has the clinical knowledge to know that warfarin was a dangerous drug and somebody could die so it had to be monitored. They also had to monitor for side effects, which is in the TAR, such as unexplained, bruising or bleeding. They did a bunch of in-servicing over the last couple of days on adverse effects of medication, high risk medications, and lab services. She stated she had to take a quiz to show her knowledge. She stated they were now checking over lab orders at shift change and it's been included in the 24-hour report. She stated it should have already been in the 24-hour report, but it was not, but it was now. She stated there was a binder at each nurse's station that had the labs that were supposed to be done in the next few days listed out as well as requisition forms. She stated she had been double checking the lab binder every time she worked even though she did not usually have responsibility for lab requisitions as an overnight staff. During an interview on 07/11/25 at 08:41 AM, LVN B stated she was PRN so she sometimes worked overnight, but she worked mostly day shifts. She stated she was the person who first noticed the bruising on Resident #1 on 07/05/25, and she was concerned about it, but she did not think to look at the labs at the time. She stated she just called the nurse practitioner. She stated they had to be able to rely on the nurse practitioner to make clinical decisions for the residents. She didn't know the outcome for Resident #1 until she came back to work to get this in-service. They talked about symptoms of anticoagulants, including some of the lesser-known symptoms. They talked about making sure that labs were done as ordered. She stated they talked about what the procedure already was that she was doing. During an interview on 07/11/25 at 08:47 AM, LVN C stated she had received in-servicing on side effects of anticoagulant and the process for making sure PT/INR was done. It was not something she was responsible for very often because she just picked up on the overnight shift sometimes, and those were usually done during the day but now she had to check the binder at each shift and check that lab requisitions had been done and labs completed. The binder was for lab services and there was one at the nurse's station. The nurse who received the order wrote the lab order in the binder and then filled out a requisition form. She stated then the lab tech looked at that and determined who to draw labs for. She stated side effects of anticoagulant medicine would be unexplained bruising, pain, bleeding especially, sometimes diarrhea, sometimes shortness of breath. She stated she learned that tongue swelling, and bruising could be an adverse effect. She stated she no longer had any patients receiving warfarin, but if she did, she knew she had to check for side effects every shift. During an interview on 07/11/25 at 09:03 AM, LVN J stated she worked exclusively overnight on the lower level and she was not the nurse for Resident #1 although she did know her. She stated she did not have any residents on warfarin or high-risk anticoagulant. She stated they did in-servicing at the

Based on observations, interviews and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 ( Resident #1) of 5 residents reviewed for quality of care. The facility failed to provide Resident #1 with a pureed diet as ordered, he asphyxiated and died . The noncompliance began on [DATE] and was corrected on [DATE]. An Immediate Jeopardy (IJ) situation was determined to have existed on [DATE]. The IJ was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey on [DATE]. This deficient practice placed residents at risk of receiving the incorrect diet leading to choking and death. Findings included: Review of the Face Sheet for Resident #1 aged 97 reflected he was admitted on [DATE] and again on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change MDS assessment for Resident #1 dated [DATE] reflected a BIMS score of 99 indicating he was unable to answer questions. His cognitive abilities were assessed as severely impaired. His functional assessment reflected he required extensive assistance for all ADLs including eating. Review of the Care Plan for Resident #1 reflected interventions were in place for: Hospice Care, ADL self-performance deficit, episodes of refusing medication, Hard of hearing- could hear some in right ear, Dementia, Pacemaker, History of falls (at home right [CONDITION(S)]), Sacral wound infection, Leukocytosis, Mechanical Altered Diet, swallowing problem r/t dysphagia, Foley catheter. Review of the Care Plan for Resident #1 dated [DATE] reflected the following interventions: ADL self-performance deficit r/t Fatigue, the instructions reflected he required set up assistance by staff to eat. Resident #1 required altered liquids (nectar thickened) and was at risk for dehydration. Unplanned weight loss r/t skin cancer- Supplements Ensure three times a day, Health Shakes twice a day and Med Pass protein supplement three times a day. Nutritional problems r/t to terminal illness - see supplements ordered by physician. Hospice Care- [DATE] Review of the previous Care Plan for Resident #1 dated [DATE] reflected he required set up assistance by staff for meals. The plan reflected he had episodes of nausea and vomiting on [DATE]. Resident #1 had unplanned weight loss r/t his cancer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Plan reflected Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of progress notes by LVN U for Resident #1 dated [DATE], reflected on [DATE] Resident #1 was observed to be choking at 6:40 pm. The charge nurse attempted the [MEDICATION(S)] (perform abdominal thrusts to remove upper airway obstructions) on Resident #1. The charge nurse then attempted to suction food from Resident #1 and managed to remove some small bits of food. Resident #1 recovered briefly and then passed away. Record review of progress notes dated [DATE] reflected Resident #1 had an incident where he was unable to swallow medications or food. He recovered to his normal function within 12 hours. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Monthly Nutrition assessment dated [DATE] reflected Resident #1 was receiving Shakes TID, Vitamin C, Juven protein supplement and Prostat supplement in response to weight loss related to his cancer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #1's Speech therapist progress and discharge summary dated [DATE] reflected he was able to swallow a small amount of thin liquids (1 tsp) he self-administered. He was able to swallow 1 tsp of mildly thick (nectar thick) liquids using cues from care givers. He was able to swallow 1 tsp of pureed diet but did not meet this goal by discharge. The therapist concluded Resident #1 should be placed on a Pureed diet with nectar thick liquids because of the high risk of aspiration. Note no further assessments were performed as Resident #1 was on Hospice Care. In an interview on [DATE] at 12:12 p.m., CNA W stated she made an error and given Resident #1 the wrong tray. CNA W stated she realized her error soon after entering Resident #1's room while LVN U was attempting to rescue him from choking. CNA W stated the charge nurse (LVN U) was assisting a resident with their meal and she was passing trays. She was unsure if LVN U checked the trays. She stated she heard people calling for help and went and saw the crash cart in Resident #1's room. She stated after she had called 911 she went and checked the tray she had served and it was the wrong one. She stated the nurse and others followed protocol, she stated Resident #1 came back briefly after suctioning for about 30 seconds and then passed away. She stated she received training in [DATE] for dietary services and verifying the correct meal for the correct resident was reviewed. In an interview on [DATE] at 8:35 a.m., the ED stated the facility had determined Resident #1 had received the wrong tray, a regular diet instead of pureed. She stated the Aide named in the incident (CNA W) had given a statement admitting she served the resident the wrong tray. The ED stated Resident #1 did some things for himself, including eating. She stated the facility investigation determined the Aide made a mistake in serving the wrong tray. The Aide was suspended pending completion of the investigation. The ED stated the family had been notified and the situation was disclosed to them. She stated all nursing staff were inserviced on the tray serving process in [DATE] and re-inserviced [DATE]. The Director stated audits of meals served on [DATE] revealed no other wrong meals were served and Resident #1's correct tray was on the cart. In an interview on [DATE] at 8:50 a.m., the DON stated the facility had begun a root cause analysis of the incident (started [DATE]). She stated no earlier problems with trays had been identified. The DON stated Resident #1 was [AGE] years old and on Hospice care for severe skin cancer. She stated he was hard of hearing and staff assisted him with most ADLs except eating. The DON stated staff would often feed Resident #1 because he was often too tired to finish his meals. In an interview on [DATE] at 8:50 a.m. the DON stated MA F was in the room when Resident #1 began to choke and called for the nurse. The DON stated during the process of trying to perform the [MEDICATION(S)] or clear the aspirated food. CNA W entered the room and stated she had served him the wrong tray. The DON stated CNA W realized her mistake and owned up to it right away. She stated all the staff who worked with Resident #1 were upset. The DON stated she had spoken with the RP and she expressed appreciation the facility had not coded her father, he had a DNR order in place. In an interview on [DATE] at 9:49 a.m., LVN T stated he had worked with Resident #1 prior to his passing but was not in facility on that day. He stated Resident #1 was pretty much bed bound and had skin cancer. He stated #1 was receiving Hospice care. He stated Resident #1 had been able to feed himself with some assistance like set up. LVN T stated Resident #1 was normally in bed with his head of bed elevated. In an interview on [DATE] at 11:00 am CNA X stated she had worked with Resident #1 and he was pleasant and funny. She stated he needed help to change his brief, clothing and wash his face. She stated he could scoot in bed a little. CNA X stated Resident #1 could feed himself sometimes and sometimes he needed help. She stated Resident #1 always received a pureed diet with thickened liquids. She stated she had not observed him choking. In an interview on [DATE] at 11:07 a.m., MA E stated Resident #1 had received his medications crushed with thickened liquids. She stated she had not observed him choking. She stated he was positioned sitting up in bed for medications. She stated he was hard of hearing and did not speak well. In an interview on [DATE] at 11:47 a.m., LVN U stated she was called to Resident #1's room by MA F. She stated when she entered the room Resident #1 was choking and his lips were turning blue. She stated she got on the bed and tried to perform the [MEDICATION(S)] maneuver. She stated MA F got the crash cart and she tried to suction Resident #1. She stated when she put her finger in his mouth to try and clear any obstruction, he bit her. She stated what looked like pieces of bread came up with suction and then Resident #1 seemed to be OK. She stated she asked CNA W to call 911. She stated EMS arrived and Resident #1 turned blue again and he had no pulse or heartbeat. In an interview on [DATE] at 12:21 p.m., MA F stated she had entered Resident #1's room to give him his medications. She stated he was sitting up 90 degrees in his bed and she observed he had a wad of food in his cheek. She asked him to spit it out because it looked like a lot. He did not respond and made a gurgling sound. She stated she was afraid he was choking and called for the charge nurse. MA F stated the charge nurse got a little bit of food out of Resident #1's mouth and she asked for the crash cart, which had a suction machine on it. She stated the nurse suctioned out a little and had performed the [MEDICATION(S)] maneuver up until that time. She stated suctioning and the [MEDICATION(S)] continued for about 10 minutes and CNA W entered and was asked to call 911. MA F stated the nurse got a little bit of food out of the resident's mouth, not much and he did come back briefly but had passed by the time EMS had arrived. MA F stated she did not normally crush Resident #1's meds but gave them with honey thickened liquids. She stated he did not like his meds crushed. She stated the aides sometimes fed Resident #1 but he also fed himself. She stated she had never observed him choking. Observation of Lunch service on [DATE] at 12:29 p.m., of the dining room revealed staff were checking resident trays, identifying residents and checking diets. LVNs T and LVN S were present. Two Residents were served nectar thickened water, both had Honey thickened liquids ordered. The nutritional supervisor clarified the nectar thickened water was appropriate for the resident with Honey thickened liquids ordered. A resident was served regular tomato soup, not thickened. LVN S removed it from his tray before serving him his lunch. Observation of meal service in rooms revealed no concerns. LVN T checked trays. All residents who required feeding assistance were taken to the dining room. In an interview on [DATE] at 12:55 p.m., CNA Y stated she had worked with Resident #1 often. She stated sometimes he did require help to eat his meals. She stated he received a pureed diet with thickened liquids. She stated she had never observed him choking. In an interview on [DATE] at 2:51 p.m., Resident #1's RP stated she and her sisters had no concerns with Resident #1's care at the facility. The RP stated the DON had talked with the family and talked about the aspiration related to a wrong tray served. The RP stated the incident was an accident and the family would not be pursuing any further action against the facility. She stated she did not believe the aide meant to hurt Resident #1. She stated Resident #1 was 97 had multiple health problems and the incident appeared to be his time to go. Record review on [DATE] of facility inservice records dated [DATE] revealed all nursing staff were educated on meal service procedures. Record review of facility inservice records dated [DATE] revealed the DON and the Dietary Manager conducted re-education on Meal Service, Tray passing and tray pass competency on [DATE]. Record review of the 24-hour Report dated [DATE] reflected Charge Nurses will need to verify diet and food on trays with CNA during all meal times effectively immediately and ongoing. Record review of Dietary Medical Nutrition Therapy Overview dated [DATE] reflected certain evidence based individualized nutrition can help treat certain medical conditions. Sections included Resident prescribed diet orders, Prescribing diet orders, Providing prescribed diets and utilizing two patient identifiers to verify identity. Note all staff inserviced starting on [DATE] and completed on [DATE]. Record review of the Tray Pass Competency Demonstration dated [DATE] reflected staff were checked on: Diet and Meal verified and compared to tray by nurse, Tray handed to staff member and diet verified by Aide against tray card, staff observed delivering tray to room, staff verifies right tray to right resident using two identifiers, and staff provides appropriate set up per resident needs. Note all staff inserviced starting on [DATE] and completed on [DATE]. Record review of the Assisting the Resident with in room meals dated ,d+[DATE] reflected residents had the right to receive meals in their rooms. Review care Plans and provide for special needs. Assemble equipment and supplies needed. Check the tray before serving to be sure it is correct diet ordered and food is appropriate to resident's needs and abilities. Prepare resident to receive meal (positioning, hand washing and temperature). Be sure Resident is served appropriately not left waiting. The final step was reflected as reporting meal outcome, documenting amount eaten or refusal to eat. The policy reflected the facility had adopted a photo identification system and name/date of birth to assure medication and treatments are administered to the right resident. Note all staff inserviced starting on [DATE] and completed on [DATE]. Review of the Inservice education for Meal Service dated [DATE] reflected Aide had signed she received the inservice. The information reflected the server should look at the meal ticket to ensure the proper diet is served to the resident. Note all staff inserviced starting on [DATE] and completed on [DATE]. In an interview on [DATE] at 8:55 a.m., the DON stated that CNA W had been terminated from the facility. She stated the incident involving Resident #1 had been reviewed by the facility Quality Assurance committee (on [DATE]) and the legal department as well as Risk Management. They elected to terminate CNA W. The DON stated CNA W was inserviced on how to serve a tray to a resident on [DATE]. She stated the normal procedure was to identify the resident, identify their tray, then check to see if the correct diet was ordered. She stated the nurse reviewed trays when the cart arrived to the floor. The DON stated CNA W did not follow the serving procedure. The DON stated residents were served meals in their rooms as the facility was just coming off COVID 19 isolation. She stated meals were back to being served in the dining room by the time surveyors entered the building. In an interview on [DATE] at 10:20 a.m., the DON stated Resident #1 was fed in bed because he was on hospice care and did not like to get up. The DON stated her review of Resident #1's hospital records reflected no other swallowing assessments had been completed since [DATE]. In an interview on [DATE] at 9:34 a.m., CNA W stated she did not check Resident #1's tray before serving it. She stated she made a mistake and had misread the diet card. She stated she did not realize she had made a mistake until she returned and saw the crash cart outside the room. She stated she had never served the wrong tray before. She stated Resident #1 would normally eat by himself, she stated she had been instructed by other staff he did not need feeding assistance. She stated other staff stated Resident #1 could eat his meal from start to finish. In an interview on [DATE] at 11:30 a.m., LVN U stated the total time of the incident with Resident #1 was approximately 10 minutes. She stated the time interval between the aide returning and the start of the [MEDICATION(S)] was maybe two minutes, a very brief amount of time. She stated initially when she yelled for assistance no one responded or yelled back, then the medication aide entered the room almost instantly. Observation of Lunch service on [DATE] at 11:35 a.m., on the Memory Care unit revealed no concerns. LVN V/Charge nurse pushed the dietary cart from room to room. She stated she reviewed a list of residents with dietary staff and reviewed diet orders. LVN V worked with CNA G and distributed trays to two residents in their rooms. Resident #7 was able to identify his name to the Aide and accepted it. CNA G then set up lunch for the resident on the bedside table. After identifying the resident's tray LVN V then checked the diet card for Resident #6 and provided CNA G with his tray to serve. She was able to confirm the name and birthday with Resident #6. In an interview on [DATE] at 11:40 a.m., LVN R stated she had been trained and educated on tray/meal service. She stated if she were monitoring the dining room, a dietary worker and herself would go over a resident list and their prescribed diets, she would check the trays to make sure diet cards and food on trays were correct. She stated a CNA would serve the tray and verify the resident's identity. In an interview on [DATE] at 11:45 a.m., RN Q stated she had received meal/tray service education or inservice. She stated after receiving the cart from dietary she would go over a list of residents and diets, also liquids served as some were thickened. She stated she would check the trays supplied against her list of residents and diets. She would supply the tray to the Aide and the Aide would verify the resident's identity, through name and Date of Birth or picture.

Based on observation, interview and record review the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 4 residents (Resident #1) who required the use of a mechanical (Hoyer) lift for transfers. The facility Administrator and DON failed to ensure that the facility policy and procedure for Hoyer Lift transfers was in accordance with manufacturer's instructions to provide a safe transfer. The facility also failed to ensure that staff were trained on appropriate procedures. This deficient practice could place four (4) residents residing in the facility that require the Hoyer lift for transfers at risk of injury. Findings include: Review of the Facesheet for Resident #1 reflected she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current consolidated physician orders [REDACTED].#1 with two people using a Hoyer lift. The initial date of this order was 3/31/10. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had unclear speech and was sometimes understood. She had severe cognitive impairment. She was totally dependent on two people for transfers. She had limited range of motion to both upper extremities and both lower extremities and used a wheelchair for mobility. Review of the Care Plan dated 8/14/13 reflected Resident #1 was at risk for falls. She was a two person Hoyer lift transfer. She had contractures of her hands and wrists related to [MEDICAL CONDITION]. She had contractures of her arms and legs due to [MEDICAL CONDITION] and she had an old right shoulder injury and required the use of the Hoyer lift for transfers. Review of the Activities of Daily Living (ADL) Documentation Log for 8/2013 and 9/2013 reflected Resident #1 was totally dependent on two persons for transfer. Observation on 10/3/13 at 9:00 AM revealed Resident #1 sitting in her wheelchair in a small dining area near the nurses' station. She stated she wanted to go to bed. Assistant Director of Nurses (ADON) assisted her to her room and asked Certified Nurse Aide (CNA) A to help her into bed. As CNA A was getting the Hoyer lift from its storage area, Resident #1 became impatient and began crying loudly. The ADON attempted to console Resident #1 who was consolable for only a few seconds before she would begin to cry again. Observation on 10/3/13 at 9:10 AM revealed CNA A and Licensed Vocational Nurse (LVN) B transferred Resident #1 from her wheelchair to her bed with a Hoyer (Mechanical) lift. CNA A spread the base of the Hoyer (adjustable chassis legs), and positioned the lift around Resident #1 ' s wheelchair. CNA A and LVN B connected the sling that was under Resident #1 to the sling attachment lugs on the lift and raised Resident #1 out of her wheelchair. They then transported Resident #1 from her wheelchair to her bed with the Hoyer lift chassis legs spread apart. Review of the Operating Instructions for the facility's Hoyer lift reflected the following: Page two (2) reflected symbols used. A warning sign was represented as a triangle with an exclamation point in the center. This symbol reflected that failure to understand and obey this warning may result in injury. Page four (4) Preparation for Use: C-warning sign-the lift must only be used in accordance with these Operating Instructions. Page 11 Using your lift: D-warning sign-Transport the lift with the chassis legs in parallell position only. Page 16 Using your lift: D-warning sign-during transport of a patient, the chassis legs should always be parallel (closed) to make maneuverability easier. Review of the facility ' s " Lift Policy " dated 2/2013 reflected the procedure can require two or three staff members to safely operate and accomplish the transfer. Prepare the lift by setting the adjustable base (chassis) to its widest position and lock in place. Raise the lift. Move the lift away from the bed. While the staff member is raising and lowering the lift, one staff member can guide the resident to the chair and another can steady the chair to receive the resident. The base on the lift should be narrowed for easier storage. In a telephone interview on 10/3/13 at 2:05 PM, the DON stated that she and the ADON trained the nurses how to perform a Hoyer lift transfer according to the facility ' s policy and procedure. The nurses, in turn, trained and checked off the CNAs based on the facility ' s policy and procedure. She stated the staff were always to use the Hoyer lift with two people. She stated the base of the Hoyer lift should be spread open during transport of the resident. Review of a " Return Demonstration Hoyer Lift Transfers " reflected the following: 1) Position sling beneath patient position the base of lift under bed or chair. Make sure lift legs are open and wheels locked. (Returning the legs to closed position was not addressed). In an interview on 10/3/13 at 12:45 PM, CNA E stated that when transporting a resident with the Hoyer lift the base (chassis) had to be closed. In an interview on 10/3/13 at 1:10 PM, CNA F stated that the base (chassis) of the Hoyer lift should be closed when moving the resident until you get them where they are going. Then open the base to lower the resident into position. In an interview on 10/3/13 at 1:20 PM, LVN G stated she did not know whether the base of the Hoyer should be opened or closed when moving a resident. In an interview on 10/3/13 at 1:30 PM, CNA J stated that the base of the Hoyer lift had to be open when transporting the resident, for stability. In an interview on 10/3/13 at 1:54 PM, CNA H stated that the base of the Hoyer had to be closed when transporting a resident. In an interview on 10/3/13 at 1:55 PM, CNA I stated that the base of the Hoyer had to be open when transporting a resident. In an interview on 10/3/13 at 3:00 PM, the ADON stated that the manufacturer recommendations for the Hoyer lift said to keep the base (chassis) closed when transporting a resident from surface to surface. In a telephone interview on 10/3/13 at 3:15 PM, the Hoyer lift manufacturer technician stated that the base (chassis) of the lift should be in open position while lifting the patient but always in a closed position while transporting a patient. He stated, " If the base was left open during transporting a patient, it ' s very hazardous. " In an interview on 10/3/13 at 3:25 PM, the Administrator stated that the facility ' s policy would be changed to reflect manufacturer recommendations and all staff would be re-inserviced beginning immediately. The ADON identified four (4) residents that required the use of a Hoyer lift for transfers.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (1) of four (4) residents (Resident #1) reviewed for mechanical (Hoyer) lift transfers. A.) On 8/8/13, Certified Nurse Aide (CNA) C failed to follow the facility's policy and procedure of using two staff members while performing a Hoyer lift transfer for Resident #1. Resident #1 fell from the Hoyer lift sustaining a Hematoma (bruise) to the back of her head. B.) On 10/3/13, CNA A and Licensed Vocational Nurse (LVN) B failed to follow manufacurer recommendations while using a Hoyer lift to transfer Resident #1 when they transferred her from her wheelchair to her bed leaving the base (chassis) of the Hoyer lift in the open position. This deficient practice could place four (4) residents residing in the facility that require the Hoyer lift for transfers, at risk for injuries due to improper transfer. Findings include: Review of the Facesheet for Resident #1 reflected she was [AGE] years old. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current consolidated physician orders [REDACTED].#1 with two people using a Hoyer lift. The initial date of this order was 3/31/10. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] reflected Resident #1 had unclear speech and was sometimes understood. She had severe cognitive impairment. She was totally dependent on two people for transfers. She had limited range of motion to both upper extremities and both lower extremities and used a wheelchair for mobility. Review of the Care Plan dated 8/14/13 reflected Resident #1 was at risk for falls. She was a two person Hoyer lift transfer. She had contractures of her hands and wrists related to Osteoarthritis. She had contractures of her arms and legs due to [DIAGNOSES REDACTED] and she had an old right shoulder injury and required the use of the Hoyer lift for transfers. Review of the Activities of Daily Living (ADL) Documentation Log for 8/2013 and 9/2013 reflected Resident #1 was totally dependent on two persons for transfer. Review of a Patient Transfer Form dated 8/8/13 reflected Resident #1 was transported to the local emergency room (ER) due to a fall from the sling of the Hoyer lift. She hit her head and had a knot/Hematoma to the back of her head. Review of Nurses ' Notes dated 8/8/13 at 3:50 PM, reflected Resident #1 fell from the Hoyer lift. She had a knot on her head. At 4:10 PM Emergency Medical Services (EMS) picked Resident #1 up. Report was called to the ER. She had a knot on her head the size of an egg with small/scant bleeding. At 6:45 PM Resident #1 returned from the ER. No new orders. No complaints of pain to the area. Neurological checks ongoing. Review of an incident report dated 8/8/13 at 3:30 PM reflected a CNA called the nurse to Resident #1 ' s room. Resident #1 was on the floor under the Hoyer lift. Upon inspection, a Hematoma was noted to the back of her head with a small amount of blood. She was transported to the ER for evaluation and treatment. Review of the facility ' s Investigation Report dated 8/9/13 reflected Resident #1 required total assistance. While being transferred from her bed to her wheelchair via Hoyer lift, CNA C knowingly chose to transfer her without a second staff member to assist. While Resident #1 was being transferred, she fell backwards and hit her head, sustaining a Hematoma. Resident #1 was sent to the ER for evaluation and treatment. CNA C was interviewed and stated she knew she was supposed to use two people when using the Hoyer lift, but Resident #1 was in a hurry so she chose to transfer her without assistance of another staff member. Staff on duty was immediately re-inserviced regarding the requirement of two people assisting with Hoyer lift transfers. Clinical engineering inspected the Hoyer lift and the sling and found both to be functional. CNA C choose not to follow proper procedure by performing the transfer without additional assistance. She stated she was trained and aware that two staff members were required. This was confirmed by reviewing her education record and her original skills competency check off dated 4/28/05 and the most recent competency check off dated 4/4/13. CNA C was terminated for not following proper procedure. Resident #1 had no long-term affect as a result of the fall. Review of hospital Discharge Instructions dated 8/8/13 reflected Resident #1 ' s final [DIAGNOSES REDACTED]. In an interview on 10/3/13 at 11:40 AM CNA C stated that she transferred Resident #1 by herself, using the Hoyer lift. While transferring, the right hook came loose from the bolt (lug) and Resident #1 fell . She stated that there was a staff member right outside Resident #1 ' s room at the time, but she did not ask that staff member to assist her with the transfer. Review of a written statement dated 8/8/13 by LVN D reflected " CNA C calls nurse to room, resident on floor, on back and crying, CNA reports fell out of Hoyer lift cradle, immediate inspection reveals egg size Hematoma at area of skull where Parietal meets Occipital. Resident answers specific questions from nurse, lucid. Stops crying and gains some composure. Small skin opening noted at hematoma which stops bleeding when pressure applied. Put into wheelchair, brought to desk of nurse, neuros (neurological) performed and PERRLA (pupils equal, round and react to light, accommodation), speaks with clarity of mind, [DIAGNOSES REDACTED]. EMS called (immediately after fall) takes resident to ER for evaluation and treatment. " Review of a written statement dated 8/8/13 by CNA C reflected " At approximately 3:45 PM I entered Resident #1 ' s room to tend her and did, at that time. She indicated she wanted to get up quickly, as she was expecting to go somewhere. She is lifted by the Hoyer, so at approximately 4:00 PM, I attached her to the lift and proceeded to transfer this patient to her chair. Upon turning and swiveling the lift mechanism, the right leg attachment instantaneously detached and her body went from upright position to upside-down position, bumping the top of her head and at the same time I held onto her and lowered the rest of her body to the floor. I called for the person outside the door to come in quickly and called upon the charge nurse, LVN D. She was then transferred to her chair and examined: applying ice. She was alert and oriented and not complaining of pain. Measures were then taken to help resident and she responded favorably. Addendum: In the course of this incident, due to fact this patient was in a hurry to get up, I chose to transfer her as one versus two person Hoyer attendance. " In an interview on 10/3/13 at 2:50 PM, Resident #1 did not recall the incident. B.) Observation on 10/3/13 at 9:00 AM revealed Resident #1 sitting in her wheelchair in a small dining area near the nurses ' station. She stated she wanted to go to bed. Assistant Director of Nurses (ADON) assisted her to her room and asked CNA A to help her into bed. As CNA A was getting the Hoyer (Mechanical) lift from its storage area, Resident #1 became impatient and began crying loudly. The ADON attempted to console Resident #1 who was consolable for only a few seconds before she would begin to cry again. Observation on 10/3/13 at 9:10 AM revealed CNA A and LVN B transferred Resident #1 from her wheelchair to her bed with a Hoyer (Mechanical) lift. CNA A spread the base of the Hoyer (adjustable chassis legs), and positioned the lift around Resident #1 ' s wheelchair. CNA A and LVN B connected the sling that was under Resident #1 to the sling attachment lugs on the lift and raised Resident #1 out of her wheelchair. They then transported Resident #1 from her wheelchair to her bed with the Hoyer lift chassis legs spread apart. Review of the Operating Instructions for the facility's Hoyer lift reflected the following: Page two (2) reflected symbols used. A warning sign was represented as a triangle with an exclamation point in the center. This symbol reflected that failure to understand and obey this warning may result in injury. Page four (4) Preparation for Use: C-warning sign-the lift must only be used in accordance with these Operating Instructions. Page 11 Using your lift: D-warning sign-Transport the lift with the chassis legs in parallel position only. Page 16 Using your lift: D-warning sign-during transport of a patient, the chassis legs should always be parallel (closed) to make maneuverability easier. Review of the facility ' s " Lift Policy " dated 2/2013 reflected the procedure can require two or three staff members to safely operate and accomplish the transfer. Prepare the lift by setting the adjustable base (chassis) to its widest position and lock in place. Raise the lift. Move the lift away from the bed. While the staff member is raising and lowering the lift, one staff member can guide the resident to the chair and another can steady the chair to receive the resident. The base on the lift should be narrowed for easier storage. In a telephone interview on 10/3/13 at 2:05 PM, the Director of Nurses (DON) stated that she and the Assistant Director of Nurses (ADON) trained the nurses how to perform a Hoyer lift transfer according to the facility ' s policy and procedure. The nurses, in turn, trained and checked off the CNAs based on the facility ' s policy and procedure. She stated the staff were always to use the Hoyer lift with two people. She stated the base of the Hoyer lift should be spread open during transport of the resident. Review of a " Return Demonstration Hoyer Lift Transfers " reflected the following: 1) Position sling beneath patient position the base of lift under bed or chair. Make sure lift legs are open and wheels locked. (Returning the legs to closed position was not addressed). In an interview on 10/3/13 at 12:45 PM, CNA E stated that when transporting a resident with the Hoyer lift the base (chassis) had to be closed. In an interview on 10/3/13 at 1:10 PM, CNA F stated that the base (chassis) of the Hoyer lift should be closed when moving the resident until you get them where they are going. Then open the base to lower the resident into position. In an interview on 10/3/13 at 1:20 PM, LVN G stated she did not know whether the base of the Hoyer should be opened or closed when moving a resident. In an interview on 10/3/13 at 1:30 PM, CNA J stated that the base of the Hoyer lift had to be open when transporting the resident, for stability. In an interview on 10/3/13 at 1:54 PM, CNA H stated that the base of the Hoyer had to be closed when transporting a resident. In an interview on 10/3/13 at 1:55 PM, CNA I stated that the base of the Hoyer had to be open when transporting a resident. In an interview on 10/3/13 at 3:00 PM, the ADON stated that the manufacturer recommendations for the Hoyer lift said to keep the base (chassis) closed when transporting a resident from surface to surface. In a telephone interview on 10/3/13 at 3:15 PM, the Hoyer lift manufacturer technician stated that the base (chassis) of the lift should be in open position while lifting the patient but always in a closed position while transporting a patient. He stated, " If the base was left open during transporting a patient, it ' s very hazardous. " In an interview on 10/3/13 at 3:25 PM the Administrator stated that the facility ' s policy would be changed to reflect manufacturer recommendations and all staff would be re-inserviced beginning immediately. The ADON identified four (4) residents that required the use of a Hoyer lift for transfers.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents and injuries when: A. One of 19 residents reviewed for injuries experienced repeated falls with only one facility intervention in place to minimize the risk of falls, and there was no re-evaluation of this intervention which was initiated (bed/chair alarms). Resident # 9 sustained a fractured hip resulting in a significant decline in his activities of daily living (ADLs). B. One of 19 residents (Resident #17) reviewed for injuries sustained a fractured left hip after being transferred from the wheelchair to the toilet by a Certified Nurse Aide (CNA). The facility did not thoroughly analyze or evaluate the incident or the CNA's competency in transfers or conduct an inservice for safe transfers. Resident #17 had a significant change in ADLs as a result of sustaining a fractured left hip and increased pain. . This facility failure places all 53 residents, identified by the facility as at risk for falls, for repeated falls and injuries, 65 residents requiring assistance for transfers at risk for injuries during transfers and 46 residents with cognitive impairment at risk for avoidable accidents and injuries . The findings include: A. Review of Resident # 9's admission face sheet he was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility incident report for Resident # 9 dated 07/21/10 at 4:50 PM revealed the following: Resident found on floor, possible fall - unwitnessed. Resident's scalp ( back ) bleeding & unable to move right leg; complains of right hip pain. Resident alert. The body diagram reveals a circle around the right hip with the comments pain; appears to be protruding. Transferred to local hospital emergency room . Further review of the incident report revealed in the section entitled " Additional comments and/or steps to prevent recurrence" was left blank. No comments were added. In the section entitled "Name, title, address & phone number of witness(es) was blank. Review of Nurse's Notes dated 07/21/10 at 5:00 PM revealed the following: Resident found on floor in the hallway by another resident's family member. Fall was unwitnessed. Resident did some bleeding to the back of the scalp and pain to right hip. 911 called. Review of the Post Fall Assessment for the 07/21/10 incident revealed: Resident's statement of incident; " I don't know what happened, I just fell ." Number of falls in the last 30 days ( including this one) : 1 2 3 4 5 or more: unmarked Was resident trying to go to BR? Yes No: unmarked Recent infection within the last 14 days? Yes marked Type: blank Personal alarm use? Yes No Alarm on resident: Yes No Alarm sounded during fall: Yes No- not marked. Under Environment - No issues. Resident last seen prior to fall, < 1 hour. Location of resident - in resident's room. Assigned Nurse - name written Assigned CNA blank Probable cause of fall: blank. Review of the Progress Notes dated 07/27/10: Follow up from local hospital revealing: the resident had status [REDACTED]. (Resident # 9 had surgery to have a pin placed in his right hip.) signed by the resident's Nurse Practitioner. Review of the facility incident report for Resident # 9 dated 07/08/10 at 2:30 PM revealed the following: Patient found sitting on floor leaning on bed. Said he slipped out of bed and had been calling for help. Stated he did not hit his head. Reported pain to RLE (right lower extremity). Bruises on right shoulder. A review of the body diagram: a bruise on the right shoulder is circled, a hematoma to the right ankle is circled, a bruise to the left elbow is marked and a skin tear to the right risk is marked. Further review of the incident report revealed in the section entitled " Additional comments and/or steps to prevent recurrence" was left blank. In the section entitled "Name, title, address & phone number of witness(es) was blank. Resident's condition before the incident: Normal, Confused Review of the Nurse's Notes dated 07/08/10 revealed the following: Resident fell at 2:30 PM. Had door closed and did not use call light. Housekeeping heard him call out and reported. Found resident sitting on floor with back against bed. Said he had slipped out of bed and had been calling for a long time. Review of the physician's orders [REDACTED].) dated 07/10/10 X-ray (R) right lower extremity & ankle R/O (rule out) fracture. May be done on Monday if no complaint of pain over weekend. Review of the P.O. dated 07/12/10 x-ray right tibia/ankle R/O fracture. Review of the x-ray report dated 07/12/10 Right Ankle, Lateral and Oblique Views; There is an old healed fracture of the distal right fibula. There is no evidence of fracture or dislocation. Review of the facility incident report dated 07/07/10 at 4:30 AM revealed the following: Resident found sitting on floor beside bed. Stated he slipped out of bed. In the section "Was a restraint in use, it is marked no. Under type of restraint mobility monitor is indicated and that "he takes it off. Further review of the incident report revealed in the section entitled " Additional comments and/or steps to prevent recurrence" was left blank. Review of facility incident report dated 05/29/10 at 5:15 PM in the resident's bathroom reveled the following: Resident noted on floor in bathroom. Resident states he had tried to change his pants and fell . Laceration noted to upper right side of back 1.7 cm. x 0.3 cm. Further review of the incident report revealed in the section entitled "Additional comments and/or steps to prevent recurrence" was left blank. No comments were added. In the section entitled "Name, title, address & phone number of witness(es) was blank. Resident's condition before the incident: Confused Review of facility incident report dated 05/26/10 at 7:30 PM revealed the following: resident discovered in his room with his left leg caught in his wheelchair - wheelchair folded up flat as he attempted to sit in it - received a 2.0 x 1.0 centimeter (cm) skin tear to lower left calf area. Further review of the incident report revealed in the section entitled "Additional comments and/or steps to prevent recurrence" was left blank. No comments were added. In the section entitled "Name, title, address & phone number of witness(es) was blank. Review of the Post Fall assessment dated [DATE] Resident's statement of incident: Resident was trying to sit in wheelchair- the wheelchair folded up with lower left extremity caught in the middle of the folded wheelchair. Fall risk score 22 ( Based on the facility's Fall Risk Assessment a total score of 10 or above represents HIGH RISK. Interventions in place to prevent fall - encouraged to use call light Personal alarm use? Yes Alarm on resident : No alarm sounding during fall: No Probable cause of fall: Lost Balance Review of facility incident report dated 05/24/10 at 1:25 PM revealed the following: Resident hollered out for help. Upon entering resident's room, resident noted on floor (ROM)range of motion (NL) within normal limits, denies hitting his head. Assisted to wheelchair. Abrasion noted on right lower leg. In the section entitled "Name, title, address & phone number of witness(es) was blank. Review of the Fall Risk assessment dated [DATE] and 07/08/10 Resident # 9 scored 15 points. In the Fall Risk Assessment a total score of 10 or above represents HIGH RISK Review of the Care Plan dated 06/18/09 for Problem: At risk for falls; Hx or Falls. Goal: Resident will not receive injury due to fall during the next 90 days. Interventions: Staff to assist Resident to transfer at all times. Keep bed in low position at all times. Assist Resident on and off commode PRN. Fall risk assessment every 90 days. Mobility Monitor From 05/24/10 through 07/21/10 the facility failed to implement a care plan or put into place interventions to prevent further falls for Resident # 9. In an interview on 08/18/10 at 1:35 PM Minimum Data Set (MDS) Coordinator stated that for Resident #9's Care Plan for Falls "that is all there is." In an interview on 08/19/10 at 9:35 AM the Physical Therapist stated Resident # 9 should not have been left unsupervised based on his confusion based on a 05/04/10 physical therapy evaluation. He stated "that's why he kept falling. anyone would know he should not be left alone for safety awareness. He was not getting enough supervision." In an interview on 08/18/10 at 12:15 PM LVN I. stated prior to his fracture and hospital stay Resident # 9 transferred himself , pushed his wheelchair as he walked behind it as well as roll himself up and down the halls. She said he was confused at times. She said he had a regular diet and texture. He would look for someone to give him a bath. She said he required little attention before the fracture and now needs help to do all his activity of daily living. She said he always had an alarm but sometimes took it off. Observations made from 08/16/10 through 08/19/10 during the survey, Resident # 9 was pushed to and from his room to the dining room by a CNA or LVN. Review of the Physicians's Consolidated orders from 02/2010 through 08/2010 Resident # 9 had a chair and bed alarm for his use. In an interview on 08/18/10 at 12:50 PM, The Assistant Director of Nursing (ADON) stated no interventions had been initiated since May 2010 when Resident # 9 started to experience falls. She said there was not a reason why no interventions were put into place. She said a mat could have been placed next to the bed or an alarm that was activated when a beam of light was broken by the resident. She said there was this kind of alarm in the building being used by another resident. In an interview on 08/18/10 at 10:30 AM the Administrator stated he was aware of the falls resident # 9 had since May 2010 and had seen a decline in him. He was aware that Resident # 9 had a fall that warranted getting an x-ray. He said the Incident/Accident log was used to track and trend falls and was discussed at staff meetings. The Administrator stated Resident # 9 could have been monitored more closely by watching him when he left an area. He said more could have done for Resident # 9 as well as the other residents. Nursing Staff is responsible for implementing investigations and follow ups to prevent accidents and ultimately he is responsible for the safety of the residents since he is the nursing staff's supervisor. The Administrator said the plant operations manager was responsible for changing batteries on the bed and chair alarms of resident. Two of the incident reports stated the resident called for help He said he did not know if anyone was responsible for monitoring the alarms to make sure they worked. He said he would find out. No information was received pertaining to a means of ensuring resident's alarms functioned properly prior to exit. Review of the Speech Therapy assessment dated [DATE] documented: Since admission to the hospital the patient has had oral intake problems. On 07/25/10 the patient failed the Modified Barium Swallow. The Section Oral Motor / Structure and Function: The patient demonstrated decreased range of motion and fluency. Oral motor and coordination & strength decreased overall prior to the event according to family and staff. Cognitive Linguistics: Patient (as per staff report) is more confused/not at baseline for cognitive /linguistic deficits. Patient prior to fall was living in a nursing home/able to communicate needs/ wants with the staff. Observation on 08/16/10 at 12:11 PM Resident # 9 was siting in his wheelchair in the dining room being encouraged to eat by a Certified Nurse Aid (CNA) It was taking multiple cues for him to take a bite of the pureed meal. An observation on 08/18/10 at 11:35 AM CNA V used a mechanical lift to transfer Resident # 9 from his bed to a standing position to his wheelchair. An interview on 08/16/10 at 12:29 PM Licensed Vocational Nurse A stated Resident #9 used to more independent with transfers and feeding himself before his fracture. He has become weaker. She said he doesn't like pureed meals and eats thickened diet supplements. She said he ate 25 % of his lunch. Review of the Quarterly Minimum Data Set (MDS)dated 05/20/10 Resident # 9 was independent for bed mobility, transfers, walking in the halls, dressing, eating and toilet use. He required limited assistance in personal hygiene and bathing. He was continent of bowel and bladder. Under disease was listed depression. Review of the MDS dated [DATE] for his re-entry from the hospital on [DATE] Resident #9 needed extensive assistance for bed mobility, transfer, dressing,toilet use and personal hygiene. He needed limited assistance with eating. He was continent of bladder but had occasionally incontinent of bowel. B. Review of facility incident report for Resident #17 dated 06/06/10 revealed the following: Resident sitting in wheelchair in room at time of assessment complaining of severe pain to left leg. Reports pain is 9 on a scale of 1-10 ( 10 being the most severe). Resident states was transferred to toilet by a Certified Nurse Aide (CNA) earlier (today) during routine care and was injured. Further review of the incident report revealed in the section entitled "Additional comments and/or steps to prevent recurrence"Bedrest at this time and mechanical lift for transfers". No CNA statements were included on the incident report. Review of radiological report for Resident #17 dated 06/08/10 revealed the following: There is a nondisplaced, impacted subcapital left hip fracture, with rotation of the femoral head. Review of Physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of physician orders [REDACTED]. May use sliding board or other method per physical therapy evaluation. Review of a facility incident report dated 08/02/10 revealed: Resident transferred via two person assist with gait belt and sliding board from bed to wheelchair. Resident sat on right hand (under slide board) and received a skin tear to right hand. Cleaned with wound cleaner and steri-strips applied (no measurements of the skin tear were documented). In the section entitled "Additional comments and/or steps taken to prevent recurrence- "instruct resident to fold arms on chest during transfer". No statements were taken from CNAs or the resident. Observation on 08/19/10 at 11:30 AM revealed Resident #17 laying in bed and informing CNAs Z and Y she was in too much pain to get up for lunch, was afraid of transferring via a slide board from the bed to the wheelchair and therefore wanted to stay in bed. In an interview on 08/19/10 at 11:30 AM Resident #17 stated she was injured by a CNA when she was transferred to the toilet. Resident #17 stated the CNA dropped her to the side of the toilet resulting in her being halfway on the toilet. Resident #17 further stated she yelled "Ow!" at the time of the transfer because her left leg was hurting. Resident #17 also stated she asked the CNA to get help but she continued to complete the transfer alone. Resident #17 tearfully stated " I don't think I will ever be the same. It hurts to get out of bed and I am scared I might get hurt again. I miss playing Bingo and getting out of my room on my own in my wheelchair". In an interview on 08/19/10 at 9:35 AM the facility's Physical Therapist stated the method residents are transferred is determined by the CNAs. It depends on how safe the CNAs feel, the resident's cognitive status and the size of the resident in comparison to the size of the CNA. Review of Resident # 17's Medication Administration Records (MARS) for the months of June 2010, July 2010 and August 2010 revealed the following: June 2010 - Vicodin 5/500 was administered 12 times for breakthrough pain in addition to scheduled Vicodin 5-500 twice daily; July 2010 Ultram 50 milligrams was administered 20 times for breakthrough pain in addition to twice daily scheduled Norco 10/325 milligrams, and Vicodin 5/500 milligrams 2 tabs was administered 13 times for breakthrough pain. August 2010- Vicodin 5/500 1 tab was administered 6 times for breakthrough pain, Vicodin 5/500 2 tabs was administered 5 times for breakthrough pain, and Tramadol 50 milligrams 2 tabs was administered 15 times for breakthrough pain. All of the pain medications required on an as needed basis were in addition to scheduled Norco 10/325 milligrams 1 tab twice daily. Review of Resident #17's May 2010 MAR ( prior to the fracture) revealed her pain from Rhabdomyolysis ( a condition of muscle pain ) was controlled with Vicodin 5/500 1 tab twice daily. In an interview on 08/19/10 at 2:30 PM CNAs Z and Y stated they had provided care for Resident #17 since her admission to the facility in July 2007. CNAs Z and Y stated prior to Resident #17 sustaining a left hip fracture she would propel herself in her wheelchair (using her feet) throughout the facility and attend activities on a routine basis. CNAs Z and Y also stated in the past Resident #17 would use the call light when she needed assistance with toileting and now she is incontinent of bowel and bladder. CNAs Z and Y further stated Resident # 17 only complained of mild pain prior to the fracture and now refuses to get out of bed for meals and activities due to pain and fear of further injury to her hip. In an interview on 08/18/10 at 1:00 PM the Director of Nurses (DON) stated because Resident #17 has a [DIAGNOSES REDACTED]. The DON further stated she thought she might have a statement from the CNA responsible for the transfer in her desk drawer (as of exit on 08/19/10 no written statement from the CNA was provided to surveyors). The DON further stated the CNA involved was not observed for safety during transfers and no inservice were conducted at the time of incident in June 2010. In an interview on 08/19/10 at 1:00 PM the DON stated CNAs are not required to demonstrate competency in skills such as transfers upon being hired but are required to watch a video for safe transfers and handling of residents during orientation. The DON further stated CNAs are not required to demonstrate competency in skills as part of yearly evaluations or during inservice training. The DON stated after reviewing incident reports for residents with injuries of unknown origin it was suspected the injuries were due to unsafe transfers however the most recent inservice for transfers since January 2010 was August 12, 2010. According to the DON the content of the inservice for transfers held in August 2010 was making determinations which residents were good candidates for Hoyer lifts or Sara lifts ( a sit to stand mechanical lift) and there were no return demonstrations by CNAs. In an interview on 08/19/10 at 4:14 PM the Administrator stated after reviewing the facility's current Abuse/Neglect policy there was no provision for cognitively impaired residents who cannot speak for themselves, injuries that are not witnessed, interviewing all staff involved in a resident's care who is injured and interviewing alert and oriented residents regarding possible abuse, neglect, or mistreatment from staff. The Administrator further stated these additions would be made to the facility's existing policy and procedures. Review of the facility's Abuse/Neglect Policy and Procedure revealed the following: Section D) Identification of Potential Problems All injuries or other incidents involving residents will be documented on a facility incident report, one copy of which goes to the DON who reviews for any patterns or trends that may suggest abuse. The Administrator and/or other staff as indicated will conduct further investigation as necessary. Section E) Investigation: Facility actions when conducting an investigation, are to be documented and include: 1. Observations, interviews and record reviews of all residents involved. 2. Interviews of all witnesses, including residents , staff, family members and any others who may have knowledge of the circumstances. 4. Examination of the physical environment in which the (alleged) incident occurred. 5. Record all relevant physical findings. 7. The DON or Administrator (ADM) will report immediately (within 24 hours) to the proper authorities any suspected abuse or neglect in accordance with current state guidelines. A facility generated list identified 53 residents at risk for fall CMS 672 identified 65 residents requiring assistance with transfers . CMS/facility 802 identified 46 residents with cognitive impairment. A facility generated list identified 20 residents transferred with a mechanical lift. The facility was found to be in Substandard Quality of Care for this deficient practice.