Every finding on record at Avir at Dallas

Based on interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences one (Resident #1) of one resident reviewed for quality of care. The facility failed to ensure Resident #1's oxygen liter flow rate matched the physician's orders. This failure could place residents at risk of not receiving appropriate treatment and care, and decreased quality of life and overall health.Findings included: Record review of Resident #1's face sheet, dated 09/27/2025 revealed an [AGE] year-old male, originally admitted on [DATE] and readmitted on [DATE], with diagnoses including iron deficiency anemia (low blood iron levels), cerebral infarction (stroke), other symptoms and signs involving cognitive function following cerebral infarction, muscle weakness, protein-calorie malnutrition, alcoholic cirrhosis of liver without ascites (scarring and damage to the liver due to heavy alcohol consumption), vascular dementia (dementia cause by brain damage form impaired blood flow), gastro-esophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), dysphagia (difficulty swallowing), apraxia (neurological condition causing difficulty to make certain movements), hypertension (high blood pressure), cognitive communication deficit, dysarthria and anarthria (difficulty using muscles for speech and producing speech sounds), paroxysmal atrial fibrillation (type of irregular heartbeat), and history of transient ischemic attack (temporary blockage of blood flow to the brain). Record review of Resident #1's MDS assessment, dated 07/20/2025, revealed he had a BIMS (brief interview for mental status) score of 04 (indicating severe cognitive impairment) and an active diagnosis of chronic obstructive pulmonary disease (lung condition caused by damage to the lungs that causes inflammation, limiting airflow). Record review of Resident #1's care plan, last review/revised on 07/18/2025 revealed the resident had the potential problem of resident has the risk for shortness of breath related to COPD, the problem start date was 12/26/2022. Record review of Resident #1's hospital discharge documents, dated 09/18/2025 and 09/19/2025, with discharge instruction summary revealed the resident had a discharge diagnosis of pneumonia. Other instructions included Disposition: Transfer to hospice facility. Oxygen: Continue NC 3 L/min for comfort. Antibiotics discontinued as focus has shifted to comfort care . Continue comfort-based measures only. Record review of Resident #1's hospital progress notes dated 09/19/2025 revealed on 09/18/2025 at 20:03 (8:03 PM), Resident #1's oxygen was changed from 3 LPM (via nasal cannula) to 2 LPM (via nasal cannula). The comment on the progress note reflected O2 Waned (weaned) RN notified RN notified RN notified - by 1L. The record showed the oxygen was kept at 2 LPM, with the last recorded time at 09/19/2025 at 18:09 (6:09 PM). Resident #1's oxygen saturation level was measured at 99-100% while he was on 2 LPM. Record review of Resident #1's progress notes on 09/19/2025 at 19:25 (7:25 PM) by LPN B reflected: Resident arrived to floor via ambulance stretcher. He is admitted LTC with diagnosis PNA. VS taken B/P 98/60 T96.9 P69 R16 SAT 97%. Resident is wearing oxygen @ 3LNC. Record Review of Resident #1's physician's orders reflected:Order: Oxygen at [_3_] LPM via N/C; Directions: every shift for For SOB and to maintain pulse ox > 90% per protocol; Start Date: 9/20/2025 06:00. Record review of Resident #1's progress note dated 09/20/2025 and created at 05:36 (5:36 AM) reflected: Resident is on follow up for readmit back to facility. Adjusting well back to facility. Staff assist with incontinent care and ADL's Remain on O2@3L via N/C. Continues to be NPO at this time. Hospice Confirmation is pending. Record review of Resident #1's progress notes dated 09/20/2025 created at 21:20 (9:20 PM) by LPN A reflected: This nurse did rounds on resident around 1500 and saw that resident's eyes were opened and looked at this nurse when his name was called, but he did not say anything. Cont to (be) on oxygen per n/c at 2LPM. During an interview on 09/27/2025 at 3:19 PM with LPN A revealed that she had came to work on 09/20/2025 and did her rounds at 3:00 PM. She said she had seen Resident #1, and he was on oxygen at 2 L/min via nasal canula. When asked who ordered the 2 L (per min), LPN A stated she assumed the doctor did because that was what the resident was on when she got to the facility. She said when she did her rounds at (3:00 PM), Resident #1 was fine. She said she looked at him and he raised his eyes at her. She further stated he was not in distress at that time, and he had just gotten done being changed and he was fine. LPN A stated she did not check the oxygen order for the resident, when she saw it was on it (2 L/min) that was what she left it at. She stated the facility had standing orders for oxygen for anyone with low saturation (oxygen levels) and did not check to see if there were written orders for oxygen. LPN A further explained she had thought the resident was going to be on hospice and did not need to check the order because he was comfortable. When asked about Resident #1's oxygen levels, she stated she did not know how low it had gotten, but that he did not have distress, and he was comfortable. LPN A discussed that if a resident was ordered 3L/min and was only receiving 2L/min and they were gasping, there was not a good oxygen and carbon dioxide exchange, and they (facility) would have resident on oxygen mask if resident were gasping. LPN A discussed that if someone was gasping from a 1L/min difference in oxygen, that indicates there is not a good oxygen and carbon dioxide exchange. She stated the 1L/min could cause a difference if the resident had COPD, but he did not have it. She said if COPD (lungs) were not perfusing oxygen (oxygen not moving through blood), carbon dioxide (levels) goes up, causing more distress of exchange. She stated if the order said 3L/min, it (the oxygen) should have been but like she had said, she did not see the order, so it stayed on 2 L/min. LPN A said she took the vitals and did not put them in the resident's electric records but in a notebook she had, she said the oxygen was not low and proceeded to get her notebook. Record review of the vitals, recorded during rounds, in LPN A's notebook reflected Sat 09/20/25. (Resident #1) 92% (oxygen saturation), 2 LPM, 98/68 (blood pressure), 16 (respiratory rate), 97.9 (temperature). During an interview on 09/27/2025 at 5:28 PM with the ADON, she stated staff were expected to review orders when residents returned from the hospital so staff know exactly what order should be or know if there were changes to their plan of care. The ADON said the hospital discontinued the facility's medication orders and did not have an order for oxygen; she said it was supposed to be continuous. She further explained the facility had standing orders for 2 L/min or 3 L/min. The ADON stated staff were expected to follow standing orders and then see what the facility doctor would want to do from there (if there needed to be a change in the standing order and/or hospital discharge order). The ADON did not find Resident #1's oxygen saturation levels of 92% while on 2 L/min a concern, and if it was a concern, she would contact the doctor and see what they wanted to do. During an interview on 09/27/2025 at 6:09 PM with the ADM, she stated LPN A should have verified Resident #1's orders because if his oxygen was set on 2 L/min, she would check to confirm, if (the order was) 3 L/min, (she) would bump it up to 3L/min. She further stated it was important to check orders to make sure residents got physician directive care orders. The ADM said staff were expected to check orders and verify again. Attempted interview with LPN B on 09/29/2025 at 09:25 AM, no response. Attempted interview with the DON on 09/2025 at 09:26A M and 01:31 PM, no response. Attempted interview with the facility's physician on 10/08/2025 at 9:51 AM, no response. Record review of the facility's Oxygen Administration policy, revised 10/2010, reflected: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders, facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident. General Guidelines1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. AssessmentBefore administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes);2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion)3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing);4. Vital signs;5. Lung sounds;6. Arterial blood gases and oxygen saturation, if applicable; and7. Other laboratory results (hemoglobin, hematocrit, and complete blood count), if applicable. Reporting1. Notify the supervisor if the resident refuses the procedure2. Report other information in accordance with facility policy and professional standards of practice.

Based on interviews, and record review, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 3 resident's reviewed for discharges. The facility failed to ensure Resident #1 had dialysis services approved on 7/29/2025 before Resident #1 was discharged from the facility. Social Worker A was informed by the dialysis center that Resident #1 was not approved for their services prior to Resident #1 being discharged . Social Worker A did not delay the discharge until dialysis services were arranged for Resident #1. Social Worker A failed to notify the facility staff of Resident #1's dialysis denial. These failures resulted in Resident #1 being discharged by RN X and Resident #1 being sent to the hospital to receive dialysis services after the dialysis clinic denied Resident #1 dialysis services. These failures could place residents at risk of not receiving the required care increasing the risk of accidents and injuries. Findings included: Record review of Resident #1's face sheet, dated 8/01/2025, revealed Resident #1 was a [AGE] year-old male born on 9/09/1968. He was listed as his own responsible party with Family Member D being his emergency contact. Record review of Resident #1's Care Plan, dated 7/20/2025, revealed that he was admitted to the facility on [DATE]. Resident #1 required oxygen related to chronic respiratory distress and acute chronic respiratory failure (body not receiving enough oxygen) & COPD (damage to the airway limiting breathing). Resident #1 needed dialysis r/t end stage renal disease. Resident #1 had diagnosis of Acute and chronic respiratory failure with hypoxia (Not receiving enough oxygen), Major depressive disorder (consistent feelings of loss or sadness), Nausea (unease and discomfort in the stomach), Anxiety Disorder (excessive fear, worry, and anxiety that interfere with daily life), Insomnia (Disorder making it hard to fall asleep or stay asleep), Gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn), Dysphagia (difficulty swallowing), Gait & Mobility Issues (balance issues), Cognitive Communication Deficit (difficulty with communication), Fatigue (tiredness or lack of energy), Dependance on renal dialysis (filter waste and excess fluids from their blood, typically due to chronic kidney disease), Hyperlipidemia (high levels of fat in the blood), Chronic Obstructive Pulmonary Disease (damage to the airway limiting breathing), Constipation (difficulty passing stools or infrequent bowel movements), Muscle Wasting (thinning of muscle tissue), Muscle Weakness (reduced strength), End stage renal disease (kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival), Anemia in chronic kidney disease (lower than normal red blood cells), Type 2 diabetes (resistant to insulin or failed pancreas), Hyperparathyroidism (high levels of calcium in the blood), and Mild protein-calorie malnutrition (abnormal nutrient absorption). Record review of Resident #1's Minimum Data Set (MDS), dated [DATE], reflected Resident #1 received Oxygen Therapy and Dialysis. Record review of Resident #1's Brief Interview Mental Status (BIMS) reflected Resident #1 had a BIMS of 13 which indicated that Resident #1's cognitive function was intact. Record Review of Resident #1's Physician Orders dated, 7/16/2025, revealed Resident #1 had an active order for continuous oxygen at 6LPM via nasal mask to keep O2 sats >90% Humidified. Record review of Resident #1's discharge planning documentation revealed that Resident #1 was issued a Notice of Medicare Non-Coverage (A NOMNC is a Centers for Medicare and Medicaid Services approved form that a provider must deliver to a patient covered under a Medicare Advantage plan who is receiving covered skilled services, such as Home Health Agency, Skilled Nursing Facility, and Comprehensive Outpatient Rehabilitation Facility services, when services are terminating in certain situations.). Resident #1 signed the agreement on 7/16/2025. The facility had not signed the agreement as of 8/01/2025. Resident #1 was to be discharged to home (Family Member D's Home) but Resident #1 wanted to transport himself from the facility to the dialysis center first and arranged his own transportation. Resident #1 had home health agency scheduled, a ramp for the stairs of the house scheduled. Resident #1's home had water, power, and no food securities. Resident #1 prefers paratransit services to commute and is eligible to discharge with paratransit services. Resident #1 owns his own oxygen with concentrator and receives 8-9 oxygen tanks per week. Resident #1 owns his own wheelchair and a 2 wheeled walker. A new 2 wheeled walker, bedside commode, and nebulizer was placed. Record Review of Facility Progress Note dated, 7/18/2025 at 1:51 PM, revealed Facility Social Worker A documented that she requested dialysis information in order for Resident #1 to secure his dialysis community chair. He was scheduled to discharge on [DATE]. Record Review of Facility Progress Note dated, 7/18/2025 at 1:52 PM, revealed Facility Social Worker A documented that Resident #1 was scheduled to discharge on [DATE]. She documented that Resident #1 will be picked up by Family Member D at 1:00 PM. She documented that she sent a new admission referral through Resident #1's previous dialysis clinic. She stated that Resident #1 was discharging with home health scheduled. She stated that Resident #1 had an appointment scheduled with nurse practitioner. Record Review of Facility Progress Note dated, 7/18/2025 at 1:52 PM, revealed Facility Social Worker A documented that Resident #1 was scheduled to discharge on [DATE]. She documented that Resident #1 will be picked up by Family Member D at 1:00 PM. She documented that she sent a new admission referral through Resident #1's previous dialysis clinic. She documented that order was placed for a rollator and bedside commode. She stated that Resident #1 was discharging with home health scheduled. She stated that Resident #1 had an appointment scheduled with nurse practitioner. Record Review of Facility Progress Note dated, 7/18/2025 at 1:52 PM, revealed Facility Social Worker A documented that Resident #1 was scheduled to discharge on [DATE]. She documented that Resident #1 will be picked up by Family Member D at 1:00 PM. She documented that she sent a new admission referral through Resident #1's previous dialysis clinic. She documented that order was placed for a rollator and bedside commode. She stated that Resident #1 was discharging with home health scheduled. She stated that Resident #1 had an appointment scheduled with nurse practitioner. Record Review of Facility Progress Note dated, 7/18/2025 at 1:52 PM, revealed Facility Social Worker A documented that Resident #1 was scheduled to discharge on [DATE]. She documented that Resident #1 will be picked up by Family Member D at 11:00 AM. She documented that Resident #1 will receive dialysis services on Tuesdays, Thursdays, and Saturdays with a chair time of 12 PM, arrival time for 11 AM. She documented that order was placed for a rollator and bedside commode. She stated that Resident #1 was discharging with home health scheduled. She stated that Resident #1 had an appointment scheduled with nurse practitioner. Record Review of the email correspondence between the facility and dialysis clinic revealed that on 7/23/2025 at 12:01 PM dialysis center sent an email to Facility Social Worker A and stated that the physician stated the dialysis clinic was still waiting on the facility to send Resident #1's flow sheets. Record Review of the email correspondence between the facility and dialysis clinic revealed that on 7/23/2025 at 12:14 PM Facility Social Worker A sent an email to the dialysis center and stated that she had already sent Resident #1's flow sheets to the dialysis center. She stated that she had already spoken with the clinic and that the clinic had confirmed receipt of the flow sheets. She stated that she was informed that Resident #1's history and physical was still needed. She stated that she re-faxed the forms again and they confirmed receipt. She stated that they were waiting on the physician to accept Resident #1 and that a response was expected to be provided on that same day 7/23/2025. No response was provided to the facility via email. Record Review of Dialysis Center Progress Note dated, 7/28/2025, revealed Dialysis Social Worker G contacted Facility Social Worker A and informed her that Resident #1 would no longer be able to receive services at the dialysis clinic. The progress note stated, Notified clinic cannot accept patient due to his oxygen requirements. Placed call to SW (Facility Social Worker A). SW (Facility Social Worker A) stated that she was told otherwise last week. This was not provided to the facility by dialysis center. Record Review of Facility Progress Note dated, 7/29/2025 at 12:40 PM, revealed Resident #1 discharged from the facility to home by RN X. Resident #1 stated that he wanted to go to the dialysis clinic from the facility before going home. Resident #1 scheduled his own paratransit company to take him to the dialysis clinic. Resident was discharged with a full tank of oxygen at 6LPM, no distress, alert x4, able to verbalize needs. Resident #1 stated that he would be coming back to the facility later that evening to pick up the remainder of his items because he can not take the items with him on the paratransit. Interview on 8/1/2025 at 10:15 AM with Executive Director F, revealed that she informed her staff not to discharge Resident #1 until everything was appropriately scheduled. She stated that Social Worker A handled the discharge process for Resident #1 and knew not to schedule his discharge unless everything was safely arranged. She stated that RN X performed the discharged as it was scheduled. She stated that the NOMNC had already activated, and the facility was already beyond its allowed limit. She stated that since Resident #1 was already discharged at the time that the facility became aware of the issue then they could not accept him back at the facility without Resident #1 going through the authorization process again. She stated that the facility first became aware of the issue once Resident #1 arrived at the dialysis clinic. There was no action taken by the facility to assist Resident #1 once Resident #1 was outside of the facility. When asked if she was aware of the phone conversation between Facility Social Worker A and Dialysis Social Worker E, she stated that she was not aware that they had called and informed the facility that Resident #1 was unable to receive their services because the medical director of the dialysis clinic denied him. She stated that if it happened the way that the dialysis center claimed then that would be unacceptable and not the proper steps for the facility to initiate a discharge process. Interview on 8/1/2025 at 10:45 AM with Facility Social Worker A revealed, Resident #1 was scheduled to be discharged to home (Family Member D's Home) on 7/29/2025. She stated that she was the one who assisted Resident #1 with discharge planning and arranging his medical needs. She stated Family Member D was aware of Resident #1's discharged because this was a planned discharge. He was to leave from the facility and go to the dialysis center and then go home. Resident #1 wanted to schedule his own transportation services to the dialysis clinic. She stated that when he arrived at the dialysis center he was declined because they had oxygen concerns and could not accept him. She stated that the dialysis clinic did not communicate that to her. She stated that all of his documentation had already been submitted via email and responded to via phone. She stated that the dialysis center approved Resident #1 via telephone call between her and Dialysis Social Worker E. She stated that there was a lot of back and forth because the dialysis physicians were having to review Resident #1's orders. She stated that everything was arranged for Resident #1 to have a safe discharged . When asked who was responsible for verifying a safe discharge she did not respond. Family Member D arrived at the facility on 7/29/2025 while Resident #1 was in the hospital. She stated that Family Member D was informed that the facility did what they could do, and she stated that she told him I did my role. She stated it was the dialysis clinic who made the mistake. She stated that they cannot tell her that they have a chair available for him and then later say after he had already been discharged that they cannot accept him. She stated that there were no documented evidence confirming dialysis had a chair available for Resident #1. Interview on 8/1/2025 at 11:00 AM with Family Member D via phone, revealed Resident #1 left from the facility to go to dialysis on 7/29/2025. When Resident #1 arrived at dialysis the staff were not prepared for him to be there. The dialysis clinic stated that Resident #1 was not registered as a client of theirs at that time. Family Member D stated that Resident #1 should have been scheduled if the facility had done their part. He stated that he was informed by the dialysis clinic that Resident #1 would not be able to receive treatment at the dialysis clinic because they could not accommodate him. The paramedics were called to transfer Resident #1 from the dialysis clinic to the hospital so that he could receive treatment. Resident #1 did not suffer from any injuries. Interview on 8/1/2025 at 11:30 AM with Dialysis Social Worker G, revealed that on Monday (7/28/2025), she spoke with Facility Social Worker A. She stated this was the day before the discharge occurred. She stated that she told Facility Social Worker A that the dialysis clinics medical director denied Resident #1 over not being able to meet Resident #1's oxygen needs. The conversation was done verbally, there were no other method of communication for the denial. The weeks leading up to the event did have a lot of back-and-forth email exchanges where the facility was being told to provide more documentation. The email chain does not state Resident #1 was ever approved for dialysis services. She stated that she documented the phone notification to Facility Social Worker A and that it was time stamped. She stated that Facility Social Worker A responded by saying something like Well, I heard otherwise. She stated that Facility Social Worker A immediately hung up the phone. Dialysis Social Worker G admitted that she was the one that had previously told Facility Social Worker A that the dialysis clinic should be able to accommodate Resident #1 the previous week but after further review the medical director determined that the dialysis clinic could not meet his needs. She stated that is why the dialysis clinic called to inform the facility on Monday 7/28/2025. She stated that she could tell that the Facility Social Worker A was upset about being told that they could not accommodate Resident #1 after already being told that they could. She stated the facility never called back, they just discharged and sent Resident #1 to the dialysis clinic the next day anyway on 7/29/2025. She stated that Resident #1 did not have any injuries and that he waited for EMS (Emergency Medical Services) to arrive to take him to the hospital so that he could receive dialysis services. She stated it takes 3 days on average for a resident to be accepted to the dialysis clinic. The doctor will review the records and make decisions about what more is required or if the residents was a candidate. If a resident is accepted to the clinic an official letter of acceptance is sent to the facility to inform them in writing of the acceptance. This letter was not sent to the facility because the resident was not accepted. Interview on 8/1/2025 at 12:00 PM with Dialysis Administrator E, revealed Resident #1 was a previous patient of the dialysis clinic in the past but had not been a patient for a while. Dialysis Administrator E stated that Facility Social Worker A was initially informed a week prior to Resident #1 being discharged that the dialysis services were scheduled. However, the physician reviewed Resident #1's medical files on 7/25/2025 and denied Resident #1 because the dialysis clinic could not meet Resident #1's oxygen needs. The following business day, 7/28/2025, the dialysis clinic Social Worker G called the facility Social Worker A and informed her that Resident #1 would no longer be able to receive dialysis services at the clinic because the clinic cannot meet Resident #1's needs. Once informed, facility Social Worker A was quoted as saying Well, that's not what I was told last week. Facility Social Worker A then hung up the phone on dialysis Social Worker G. The following day, 7/29/2025, Resident #1 arrived at the dialysis clinic although the facility had been informed the day prior that Resident #1 would not be able to receive their services. The reason for the denial was because the doctor had previously told the facility they would be able to accept them but once it was reviewed by the medical director that changed. Resident #1 requires 6 to 8 liters of oxygen continuously. The dialysis clinic stated that they could not handle that because their oxygen concentrators only allow 5 liters. The dialysis clinic does not think Resident #1 should have been discharged to receive dialysis services from them when the facility was informed that they could not meet his needs prior to his discharge being completed. Interview on 8/1/2025 at 1:00 PM with Facility Social Worker A revealed, the facility was never informed of Resident #1 being denied by the dialysis clinic. She stated that she was initially informed by the dialysis clinic the week before the discharge that Resident #1 was approved for dialysis services. She stated that nobody called to tell her otherwise. She then stated they called after Resident #1 had already been discharged so it was out of the facilities control at that point because the facility could not take back a resident that had already been discharged . When asked why would the dialysis center state that they informed Facility Social Worker A of Resident #1's denial she stated that it was not true. When asked why the dialysis clinic would state that Facility Social Worker A hung up on the phone when informed of Resident #1's denial she stated that she did not know. Interview on 8/19/2025 at 10:30 AM with Physician Q revealed, Resident #1 was offered dialysis services the day before discharge and on the day of discharge before he left the facility. Resident #1 refused dialysis services because he wanted to go to the dialysis clinic instead of receiving dialysis in the facility. The risk of him having complications within the next 24-48 hours at time of discharge was low. It was not a life-threatening moment for him to have it done on the day of discharge but he should have had it within the next 24 to 48 hours. If he didn't then he could retain too much fluid and have difficulty breathing which would have required a visit to the hospital. This situation was at a limited risk of causing him harm. The dialysis center had 2 weeks' notice that Resident #1 would be coming back to them. Resident #1 was very educated about his illness and could manage his care to a great extent. Resident #1 should have had dialysis appointments scheduled, certainly. There should have been better communication between the facility and the dialysis center about his oxygen needs. This would have caused the facility staff to try to address it as soon as possible. The arrangements are normally 12-24 hours for supplies if a resident requires more assistance to receive care and that should have been able to be accommodated. He should have been able to receive services. If not on the day of discharge, the following day he could have easily received dialysis. That would place him at a low risk. She stated that she saw Resident #1 at the nursing facility. She stated Resident #1 was not affected mentally or physical by this visit. That he appeared to be happy with the level of care he was receiving at the facility. The referral to have him re-admitted after his hospital visit was made and accepted by the insurance company. Interview on 8/19/2025 at 11:00 AM with Medical Director R revealed, Resident #1 was offered dialysis services the day before discharge and on the day of discharge, but he refused. She stated that Resident #1 needs an average of 6-8 liters of oxygen and that it was not normal for the dialysis clinic to accept a resident with those needs. She stated that the clinic was not equipped to meet the needs of the resident at that time. She stated that the resident was in a facility that already could provide him dialysis and that he was offered multiple times and has a history of refusal. She stated that the dialysis clinic was equipped to care for Resident #1 if he was to decide to come back to the dialysis clinic in the future because they have purchased supplies to meet his oxygen needs. She stated that Resident #1 was back at the facility because he was accepted after his hospital visit. She stated that Resident #1 was denied because they only had the supplies to care for someone who received up to 5ml of oxygen. She stated Resident #1 was a very difficult patient to work with and that he refused dialysis treatments even when he knew the risks. She stated that he was a previous patient of theirs in the past. She stated that if he received dialysis on the day of discharge then there is no risk. She stated that he had 24-48 hours to receive services before there was a risk of harm. She stated that he advocated for himself and has the cognition to do so. She stated that the dialysis clinic would have issued an acceptance letter if Resident #1 was accepted to the facility. There was never an acceptance letter sent to the facility for Resident #1. Interview on 8/20/2025 at 10:44 AM with Resident #1 revealed, Resident #1 was back at the nursing facility. He stated that he is fine, and he has no issues with the care that he receives at the facility. He stated he is happy with the staff but that he was not happy with how the discharge process was handled. He stated that he did in fact receive dialysis at the facility the day before he was discharge. He stated that he did not refuse dialysis on the day of discharge prior to discharge. He stated that he thought he was going to receive dialysis services at the dialysis clinic after he was discharged but they denied him, so he had to go to the hospital to receive his dialysis services. He stated now that he is back at the facility everything is okay. Interview on 8/20/2025 at 12:11 PM with Dialysis Technician S revealed, Resident #1 did receive dialysis on 7/28/2025 the day prior to his discharge. She stated that Resident #1 did have a history of refusing to receive dialysis services. She stated that on the day of discharge 7/29/2025, Resident #1 refused to receive dialysis services at the facility because he wanted to wait until he arrived at the clinic. She stated that Resident #1 was aware and that if he did not want to receive dialysis then she could not make him receive dialysis. She stated she was responsible for notifying the physicians that the resident refused dialysis. She stated that Resident #1 preferred to discharge to his outpatient clinic. Record Review of the Transfer and Discharges section of the Resident Rights Policy, dated 11/2021, states that residents have the right to:Not be discharged from the facility, except in accordance with nursing facility regulations. Record Review of the Transfer and Discharges Policy, dated 12/2017, states that discharged residents will have documentation related to discharge or transfer in clinical software.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed on 07/23/2025 to ensure food items in the facility walk-in refrigerator was dated. 2. The facility failed on 07/23/2025 to ensure the seasoning containers were tightly covered.3. The facility failed on 07/23/2025 to ensure the top and back of the oven was clean and free from debris and dust.4. The facility failed on 07/23/2025 to ensure the ice making machine was free from leaks and accumulation of scale. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.Findings included: Observation on 07/23/2025 at 9:18 AM of the kitchen revealed: An open box of single packet sour cream was not dated in the walk-in refrigerator. Seasoning containers of black pepper, whole celery seed, garlic powder, Italian seasoning, meat tenderizer were not tightly covered and exposed to air. The top back of the oven had oil debris and dust buildup. The ice making machine was leaking and had scale accumulation around it. An interview on 07/21/2025 at 9:26 AM with the Dietary Manager who stated she and her 9 employees that were responsible for dating, covering food items, and keeping the kitchen equipment clean. She stated her expectation was all food items in the kitchen should be marked with received date once they arrive at the facility and used by date for leftovers and opened food items, and all food items should be appropriately dated, covered for freshness, and labeled by the kitchen staff. She stated the risk of not dating, covering food items, not cleaning and maintaining the ice machine and oven could cause cross contamination, growth of bacteria, resulting in food borne illness. She stated all employees were in serviced regarding dating, labeling, covering food items and cleaning, properly maintaining kitchen equipment. An interview with [NAME] on 07/23/2025 at09:36 AM stated he and all other kitchen staff were responsible to make sure the food items were covered, dated and labelled, the ice machine and oven were clean. He stated not dating, covering food items and not cleaning and maintaining kitchen equipment could cause residents to get sick due to food borne illness. [NAME] stated he had received training regarding food and kitchen equipment handling within the past two months. An interview with the facility Dietician on 07/22/2025 at 1:38 PM stated covering and putting date on foods items were important to ensure freshness, rotation of first in and first out of that item. She stated she expected the kitchen staff to put date when they receive the food item and when they open it. Dietician stated it was important to ensure kitchen equipment such as oven and ice machine were clean to ensure food was safe to serve. Record review of the facility policy titled food storage with a revised date of June 1, 2019, reflected: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guidelines. Dry storage: To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labelled and dated. Refrigerators: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of the facility policy titled General Kitchen Sanitation: dated October 1, 2018, reflected The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and foodservice employees will maintain, clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Clean and sanitize all food preparation areas, food contact surfaces, dining facilities and equipment. Keep food contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt and food particles and otherwise in a clean and sanitary condition. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. (B) .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: (1) The day the original container is opened in the food establishment shall be counted as Day 1; 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

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #15 and Resident #21) of 3 observed for infection control. The facility failed to ensure:1- CNA F changed gloves during incontinent care for Resident #21 on 07/21/2025.2- CNA G performed hand hygiene and changed gloves during incontinent care for Resident #15 on 07/21/25.These failures could place residents at risk for infection and cross contamination of pathogens and illness.Findings included:1.Record review of Resident #21's Quarterly MDS assessment dated [DATE] reflected Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus, and elevated blood pressure. Resident #21's BIMS score of 08, which indicated Resident #21's cognition was moderately impaired. The MDS assessment indicated Resident #21 required maximal assistance with toileting hygiene.Observation on 07/21/25 at 10:40 AM revealed CNA F was in Resident #21's room to provide incontinence care. CNA F had gloves on, she unfastened Resident #21's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. She rolled resident on her side. CNA F wiped the resident's buttock area with peri-wipes, front to back, she then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. She rolled the resident on her back onto the clean brief. Once finished, she fastened the resident's brief. She removed and discarded her gloves and washed her hands. In an interview on 07/21/25 at 12:30 PM, CNA F stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA A stated failing to provide proper care exposed the resident to infections. 2.Record review of Resident #15's Quarterly MDS assessment dated [DATE] reflected Resident #15 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), muscle weakness, and need for assistance with personal care. Resident #15's BIMS score of 13, which indicated Resident #15's cognition was intact. The MDS assessment indicated Resident #15 required maximal assistance with toileting and personal hygiene. Observation on 07/21/25 at 12:38 PM revealed CNA G entered Resident #15's room to provide incontinence care. CNA G washed his hands and donned gloves, he unfastened Resident #15's brief, he cleaned her front pubic area with wipes. CNA G changed his gloves without performing any kind of hand hygiene. He rolled resident on her side revealing small bowl movement. CNA G wiped the resident's buttock area with peri-wipes, front to back, removing the fecal material. CNA G then removed the soiled brief and changed gloves without performing hand hygiene. He placed the clean brief under the resident and applied barrier skin to the resident's buttocks. CNA G changed his gloves without hand hygiene. He rolled the resident on her back onto the clean brief, he applied skin barrier to the resident's pubis area and the groins area. CNA G changed gloves without hand hygiene. Once finished, CNA G fastened the resident's brief. In an interview on 07/21/25 at 12:45 PM, CNA G stated he should perform hand hygiene between change of gloves when he went from dirty to clean. CNA A stated failing to provide proper care exposed the resident to infections. CNA A stated he was trained to sanitize hands between change of gloves. In an interview on 07/23/25 at 3:50 PM, DON stated he expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. DON stated CNAs where trained to perform hand hygiene between change of gloves. DON stated failure to do so would potentially lead to cross-contamination and possible spread of infection. DON stated the ADONs would do random rounds for monitoring. Record review of the facility's policy, Hand Washing, dated December 2017, reflected, .Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . Before and after assisting a resident with personal care . After removing gloves or aprons .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Nurses Cart 300 Short Hall) of 3 medication carts reviewed for pharmacy services.The facility failed to ensure LVN I responsible for Nurses Cart 300 Short Hall, removed medications in unsecure containers from the Nurses Cart on 07/21/2025 when a controlled medication used for pain had broken seals.This failure could place residents at risk of not having the medication available due to possible drug diversion.The findings included:Record review and observation on 07/21/25 at 12:57 PM of Nurses Cart 300 Short Hall, with LVN I revealed the blister pack for Resident #24's hydrocodone acetaminophen 5-325 mg tablet (controlled medication used for pain) had 2 blister seals broken and the pill still inside the broken blister and taped over.Interview on 07/21/25 at 1:03 PM, LVN I stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters. She stated the risk would be a potential for drug diversion. LVN I stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shifts. She stated when a broken seal was observed, she would waist the pill with another nurse. Interview on 07/23/25 at 3:50 PM, the DON stated he expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened or tapped over. The DON stated the risk would be potential for drug diversion. He stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADONs were supposed to check the carts weekly. The DON stated the pharmacy consultant checked the carts monthly and he stated ADONs were supposed to check of the medication carts for monitoring.Record review of the facility's policy titled Medication Storage - in the Home, dated December 2017, revealed in part . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medication destruction, and reordered from the pharmacy .

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when doing so would endanger the health or safety of the resident or other residents for 1 of 23 residents (Resident #33) reviewed for reasonable accommodation of needs.The facility failed to ensure the call light device was within the reach of Resident #33 on 07/21/2025 when the resident was lying in bed in his room.This failure could have placed residents at risk of being unable to have a means of directly contacting the caregivers.Findings included: A record review of Resident #33's MDS dated [DATE] revealed he was a [AGE] year-old male with an admission date of 07/03/2025 and a BIMS score of 14, which indicated intact cognition. Resident #33 had a diagnosis of stroke (damaged brain cells due to reduced blood flow), history of falling, and hip fracture. Resident #33 was occasionally incontinent of urine, frequently incontinent of bowel, and required substantial/maximal assistance with bed to chair and toilet transfers.A record review of Resident #33's care plan dated 07/10/2025 reflected he used a wheelchair for mobility and was at risk for falls, at risk for skin breakdown and pressure ulcers related to incontinence and impaired mobility. Goal: (Resident #33) would remain free from injury. Approach: Gave (Resident #33) verbal reminders not to ambulate/transfer without assistance. Observation and interview on 07/21/2025 at 11:29 AM revealed Resident #33 who was lying in bed. Resident #33's call light was kept on the bedside stand, away from Resident #33, and Resident #33 was unable to reach his call light device. Resident #33 stated he could not find his call light device. An interview with CNA A on 07/22/2025 at 2:50 PM stated she had worked at the facility for two months and she worked on different halls. CNA A stated she ensured the call light was always within reach of the resident before she left a resident's room after providing care. She stated it was all employees' responsibility to ensure the call light was within resident's reach. She stated not having a call light within reach of a resident could have led to fall risk, injury, not receiving emergency care, not receiving timely incontinent care, and skin damage. She stated she had received in-service training on call lights within the past three weeks. An interview with LVN D on 07/22/2025 at 3:25 PM stated she expected the resident's call light had to always be within reach and all employees who went into a resident's room were responsible for making sure the call light was within reach of that resident. She stated she received in-service on call lights twice a month along with other employees and not having a call light within reach could have led to residents becoming frustrated, not receiving emergency care, falls, and injury. An interview with CNA B on 07/22/2025 at 3:36 PM stated she had worked at the facility for a month. She stated call lights were life saver, and she always made sure the call light was within reach of the resident whenever she went to a resident's room. She stated not having a call light within reach could have increased the risk for falls, injuries, and even death of the resident by not getting timely care. She stated all staff were responsible for making sure the call light was within reach of the resident, and she had received orientation and in-service training on call lights. An interview with RN E on 07/23/2025 at 11:45 AM stated the call light should have been within the resident's reach at all times, and she expected all staff to ensure the call light was within resident's reach before they exited the resident's room. She stated not having a call light within reach of a resident could have caused falls, injuries, and death. She stated she had received in-service training on call lights that week. An interview with the DON on 07/23/2025 at 3:59 PM stated he expected the call light to be within reach of the resident and it was all the employees' responsibility to make sure the call light was within the reach of the residents. He stated the residents were at risk for not receiving ample care, falls, and injuries if the call light was not within reach. He stated all employees received in-service training on call lights every month. A record review of the facility's call light policy dated 12/2017 revealed: It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use. When providing care to residents, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. Be sure call lights are placed near the resident, never on the floor or bedside stand.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #1 & #2) reviewed for care plans. 1. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #1's diet was a puree diet as ordered on 07/10/25.2. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #2's diet order for double protein portions as ordered on 06/13/25. This deficient practice could place residents at risk of not receiving the necessary care or services.Findings included: 1.Record review of Resident #1's Comprehensive MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of dementia (loss of cognition), heart failure, and dysphagia (difficulty swallowing). She had a BIMS of 7 (severely impaired cognition). Record review of Resident #1's care plan, dated revised 06/13/25, reflected she was on a therapeutic diet due to being NPO (nothing by mouth) and had a feeding tube due to dysphagia (difficulty swallowing). Interventions included the dietary manager to monitor and discuss food preferences and provide feedings and water flushes as ordered. Record review of Resident #1's physician orders reflected diet NPO with a start date of 06/04/25 and end date of 07/10/25 and an order for a Regular Diet-Puree, liquids, thin with a start date of 07/10/25. In an interview on 07/21/25 at 9:50 AM with Resident #1 revealed she used to be NPO due to a feeding tube and she currently was on a pureed diet. 2.Record review of Resident #2's MDS reflected he was a [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of heart failure, dementia (loss of cognition), and kidney failure. He had a BIMS score of 13 (intact cognition). Record review of Resident #2's care plan, dated 06/06/25 reflected he was on a liberalized renal diet and interventions included monitoring and discussing of food preferences with the Dietary Manager and offer snacks within diet. Resident #2's care plan did not reflect a meal supplement or double protein portions. Record review of Resident #2's physician orders reflected Renal diet- regular texture, thin liquids; double protein portions. with a start date of 06/13/25. In an interview on 07/23/25 at 11:04 AM with Resident #2 revealed he received double protein for meals and was included in care planning and did not recall meals being discussed. In an interview on 07/23/25 at 1:33 PM with the Regional MDS Nurse Consultant revealed she was responsible for creating and updating care plans. She reviewed Resident #1's care plan and stated the care plan did not reflect resident was on a pureed diet and showed she was NPO and had a feeding tube. She stated Resident #1's care plan should have been updated to reflect the change in her diet. She reviewed Resident #2's care plan and stated she did not think an order for double protein and health supplement would be something they care planned because it was too specific. She stated it was important to ensure a resident's care plan was specific. In an interview on 07/23/225 at 2:36 PM with the DON revealed the MDS Nurse was responsible for care plans, and he expected care plans to be resident centered and the be up to date with their diet. He it was important to ensure the resident's care plan accurately reflected their current diet orders because it directed the resident's plan of care. In an interview on 07/22/25 at 1:38 PM with the Dietician revealed she spoke with Resident #1 on 07/16/25 and was NPO at the time and did not recall any changes to her diet. She stated Resident #2 was on a renal diet and she spoke with him on 07/13/25 and updated his diet order, he requested a supplement and double protein portions. She stated when she updated a resident's diet, she sent the information to the clinical team including the DON and Dietary Manager to ensure everyone was aware of changes. She stated it was important to ensure resident diets were care planned and updated upon changes in orders to ensure they received the adequate protein and calories and reflected their food preferences. In an interview on 07/23/25 at 2:11 PM with the Dietary Manager revealed Resident #1 was on a puree diet and used to be NPO (nothing by mouth). She stated Resident #2 was on a renal diet. She stated she was not aware Resident #1 and Resident #2's care plans were not updated to reflect their orders. She stated that it was important to ensure the resident's diet was care planned to ensure their food preferences were honored. She stated that resident's diet orders automatically changed their meal tickets and Resident #2 had been receiving a puree diet as ordered and Resident #2 received double protein. Record review of the facility's care plan policy, titled Care Plan- Resident, dated December 2017, reflected: .It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. Approach/Plan.b. Coordinate care to be provided to the resident for the most effective, efficient utilization of resources.c. Individualize care to ensure the care plan is person centered for the unique needs of the resident.d. Communicate vital information to staff providing direct resident care.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #82) of 23 residents reviewed for ADLs. The facility failed to ensure Resident #82 had his fingernails cleaned and trimmed on 07/23/2025. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included: Record review of Resident # 82's face sheet dated 07/23/2025 revealed he was a [AGE] year old male with an admission date of 07/14/2025, diagnoses include Encephalopathy (Brain disfunction which can severely impact cognitive abilities, hinder ability to perform routine tasks, maintain personal hygiene), Undifferentiated Schizophrenia (a mental illness affecting thought and ability to function independently), Necrotizing fasciitis (An illness that ca lead to significant functional impairment and reduced quality of life), Type 2 diabetes mellitus without complications (elevated blood sugar levels). Record review of Resident #82's care plan dated 07/22/2025 reflected he had ADL self-care performance deficit and required staff assistance. Resident #82 had frequent episodes of urinary and bowel incontinence; he was at risk for impaired thought process related to Encephalopathy. An observation and interview on 07/21/2025 at 2:40 PM with Resident #82 revealed he was on isolation precaution due to positive Covid-19 (Infectious disease caused by SARS-CoV-2 virus, affects the respiratory system) diagnosis, he was lying on his bed. Resident #82 had long, dirty fingernails, he stated he would like it to be trimmed and cleaned, but nobody offered him assistance yet. An interview with LVN D on 07/22/2025 at 3:25 PM stated she was the nurse for Resident #82 that shift. She stated Resident #82 had a diagnosis of diabetes; she was not aware Resident #82 had a long dirty fingernail. She stated she expected fingernail trimming to be completed during the shower and as needed. She stated long dirty fingernails could cause harmful germs to grow and increase the risk of infections. She stated she had received Inservice on fingernail care within that month. An interview with CNA B on 07/22/2025 at 3:36 PM at Resident #82's room stated she saw Resident #82's long dirty fingernails when the surveyor brought it to her attention. The interview continued outside resident's room; CNA B stated she did not notice resident #82's long fingernails when she provided care to him. She stated dirty long fingernails can cause skin tear, harbor harmful germs and bacteria, infections and illness. CNA B sated she would let her nurse know if a resident had a long dirty fingernail and she would follow her nurses' instructions. She stated nurse was responsible to trim a resident's fingernail if that resident had elevated blood sugar level. She stated she had received in services, frequent reminders about fingernail care since she started working at the facility a month ago. An interview with RN E on 07/23/2025 at 11:45 AM stated the nurse and the aide were responsible to clean and trim resident's fingernails during bath days and as needed. She stated if a resident was diabetic, the nurse was responsible to trim the fingernails, and the nurse could do the cleaning after checking with the nurse. She stated long dirty fingernails increased the risk for infections, illness and skin tear. She stated the charge nurse was responsible to trim Resident #82's fingernails since he was diabetic. She stated she and her staff received in service on fingernail care every month. An interview with the DON on 07/23/2025 at 03:59 PM stated he expected the resident's fingernails to be cleaned and trimmed as needed. He stated if a resident preferred to have long fingernails, it had to be care planned. He stated the nursing team was responsible to ensure all residents had clean and trimmed fingernails unless they refused. He stated long dirty fingernails could affect the skin integrity and cause infections. DON stated all the employees received in services on fingernail care on every month and as needed. Record review of facility policy titles nail/hand and foot care dated 12/2017 reflected it is the policy of this home to ensure residents receive nail care (hand and foot) in a safe manner. Precautions: Nursing assistants will provide nail care to those residents who requiring assistance . nursing assistants will follow home guideline for hand, foot and nail care, nursing assistants will receive permission and instructions from the charge nurse prior to cutting fingernails or toenails.

Based on interview, 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 of each resident for 1 (Nurses Cart 300 Short Hall) of 3 carts reviewed for pharmacy services. The facility failed to ensure LVN J, LVN K, and LVN L responsible for Nurses Cart 300 Short Hall, counted all controlled drugs for every shift change on 06/07/2025, 06/08/2025 and 06/16/2025 when LVN I and Surveyor reviewed the count sheets on 07/21/2025.This failure could place residents at risk of not having the medication available due to possible drug diversion.Findings included:Record review and interview on 07/21/25 at 12:57 PM of Nurses Cart 300 Short Hall, with LVN I (nurse responsible for the Nurses Cart 300 Short Hall) revealed missing signatures for Off duty and On duty for 06/07/2025 (10:00 PM to 6:00 AM shift), 06/08/25 (2:00 PM to 10:00 PM shift), and 06/16/2025 (6:00 AM to 2:00 PM shift) of the narcotic count sheet. LVN I stated nurses were responsible to sign the narcotic sheet after counting the narcotics at the beginning and at the end of the shift. Interview on 07/23/2025 at 12:18 PM, LVN K stated she should have signed the narcotic sheet after counting the narcotics, on 6/8/25 at the beginning and at the end of the shift 2 PM to 10 PM. She stated she was not sure why she did not sign the count sheet. She stated she knows that she supposed to sign immediately after the count was done. She stated the risk would be potential for drug diversion. Interview on 07/23/25 at 12:31 PM, LVN J stated she should have signed the narcotic sheet after counting the narcotics on 6/7/25 at the beginning and at the end of the shift 10 PM to 6 AM. LVN J stated, I counted the narcotics, but I forgot to sign. LVN J stated this failure could potentially cause a drug diversion. She stated she was trained and learned that she supposed to sign the narcotic count sheet immediately after counting with the other nurse. Attempted to call LVN L on 07/23/25 at 12:38 PM who worked on 06/16/2025 and was missing LVN L's signature. Interview on 07/23/25 at 3:50 PM, the DON stated he expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, he was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADONs would weekly check the carts for monitoring.Review of the facility's policy Narcotic Count dated December 2017, reflected . 1. The nurse coming on duty and the nurse going off duty must count and justify narcotics supply for each individual resident at the change of shift. 2. Each nurse counting must record the date and his/her signature verifying that the count is correct on the [Narcotic Count Sheet], at the beginning and end of each shift.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident did not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers/injuries. 1. The facility failed to monitor early signs of a pressure injury (PI) to promote the prevention of pressure ulcer (PU) development to Resident #1's right medial foot and great toe. On 02/07/25, the hospice health aide reported a large blood blister on the right foot and a bruise to Resident #1's right medial foot and great toe to LVN D. LVN D reflected the blood blister on the Weekly Skin assessment dated [DATE]. Skin barrier cream was applied to the site(s) daily. On 03/02/25, the hospice RN assessed the site and ordered skin prep for application to the dried blister on Resident #1's right medial foot and great toe every shift (3 times a day [6A - 2P, 2P - 10P, and 10P - 6A]). On 03/18/25, the WMD was consulted to assess, evaluate, and treat Resident #1 for an unstageable (due to necrosis) pressure ulcer at the right medial foot and great toe. 2. The facility failed to monitor early signs of a pressure injury. On 02/26/25, the hospice health aide reported a purple pressure area on Resident #1's left hip to LVN E. LVN E reflected an intact reddened area to Resident #1's left hip on the Weekly Skin assessment dated [DATE]. The facility failed to perform a weekly skin assessment for Resident #1 on 03/06/25. On 03/09/25, LVN A completed a weekly skin assessment that indicated Resident #1 had an abrasion described as Eschar noted to left hip and abrasion/wound reopened right below the necrotic area . after Resident #1's RP called LVN A and ADON I to the room to look at a wound discovered on Resident #1's left hip. On 03/18/25, the WMD was consulted to assess, evaluate, and treat Resident #1 for an unstageable (due to necrosis) pressure ulcer to the left hip. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/09/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents admitted without wounds, to develop wounds, and placed at an increased and unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings included: A record review of Resident #1's Admission MDS assessment, dated 11/18/24, revealed a [AGE] year-old female. On 11/11/24, Resident #1 admitted to the facility on hospice services. Resident #1 had a BIMS Summary Score of 10, that suggested Resident #1 had a moderate cognitive decline. Resident #1 had diagnoses that were primary risk factors for pressure injury development that included CHF; COPD; Impaired mobility and decreased functional ability, leg contracture; Parkinson's; and Dementia. Resident #1 had an impairment to the lower extremity on both sides. Resident #1 required substantial/maximal assistance with eating, oral hygiene, rolling from lying on back to left and right side, and return to lying on back on the bed. Resident #1 was dependent with all other ADLs. Resident #1 did not have any wounds on admission to the SNF. Resident #1 discharged to the hospital on 03/29/25. Record review of an Unavoidable Pressure Ulcer Assessment Form dated 01/15/25, completed on Resident #1, was signed by the WCN and WMD during a QAPI meeting. Record review of Resident #1's Discharge MDS assessment, dated 03/29/25, revealed Resident #1 had unhealed pressure ulcers/injuries, one (1) Stage 3 pressure ulcer, two (2) Stage 4 pressure ulcers, and one (1) unstageable pressure ulcer due to coverage of bound bed by slough and/or eschar. Record review of Resident #1's comprehensive care plan was developed on 02/16/25. The last care conference was 03/17/25. The comprehensive care plan reflected: [Resident #1] had contractures and was at risk for skin break down, increased pain from affected areas and injury [Problem Start Date: 11/11/24; Edited: 02/16/25]. Care plan goals indicated Contractures will not increase, skin break down will not occur, increased pain will be relieved within one hour of intervention and no injuries will occur over next 90 days [Edited: 02/16/25; Target date: 5/11/25]. Interventions included Assist with repositioning often using positioning devices to maintain proper body alignment, provide for comfort measures as needed and Provide pressure relieving devices on bed and chair [Approach Start date: 11/11/24; Edited: 02/16/25]. [Resident #1] was at risk for pressure ulcers r/t incontinence status/Dementia [Problem Start Date: 11/11/24; Edited: 02/16/25]. Care plan goals indicated Resident's skin will remain intact [Edited: 02/16/25; Target date: 5/12/25]. Interventions included Avoid shearing (a combination of downward pressure and friction) resident's skin during position, transferring, and turning; Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences; Keep bony prominences from direct contact with one another; and Report any signs of skin breakdown (sore, tender, red, or broken areas). [Approach Start date: 11/11/24; Edited: 02/16/25]. [Resident #1] had a pressure ulcer to sacrum (a large, triangular bone at the base of the spine). [Problem Start Date: 03/10/25; Created: 03/31/25]. Care plan goals indicated will heal without complications [Created: 03/31/25; Target date: 03/10/26]. Interventions included Apply dressings per MD order; Assess resident for pain related to pressure ulcer or its treatment. Prevent or treat pain by medicating per order; Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin ____ (frequency); Keep clean and dry as possible. Minimize skin exposure to moisture; Supplements: per MD; Turn and reposition every 2 hours; Use heel protectors to relieve pressure on the heels; and Use moisture barrier product to perineal area [Approach Start Date: 03/10/25; Created: 03/31/25]. [Resident #1] had a pressure ulcer to right medial foot. [Problem Start Date: 03/10/25; Created: 03/31/25]. Care plan goals indicated ulcer will heal without complications [Created: 03/31/25; Target date: 03/10/26]. Interventions included Use heel protectors to relieve pressure on the heels; Apply dressings per MD order; Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin ____ (frequency); Keep clean and dry as possible. Minimize skin exposure to moisture; Supplements: per MD; and Turn and reposition every 2 hours if allowed [Approach Start Date: 03/10/25; Created: 03/31/25]. [Resident #1] had a pressure ulcer to left hip. [Problem Start Date: 03/10/25; Created: 03/31/25]. Care plan goals indicated [Resident #1] will have intact skin, free of redness, blisters, or discoloration by/through review date. Will show signs of healing and remain free from infection by/through review date [Created: 03/31/25; Target date: 03/10/26]. Interventions included Administer protein supplements as ordered; Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD; Inform family/caregivers/MD of any new area of skin breakdown; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Requires a cushion to wheelchair or Geri chair when sitting up; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; Requires the use of an air mattress; and Wound care MD consult PRN [Approach Start Date: 03/10/25; Created: 03/31/25]. [Resident #1] had a pressure ulcer to the right, medial first toe. [Problem Start Date: 03/10/25; Created: 03/31/25]. Care plan goals indicated [Resident #1] will have intact skin, free of redness, blisters, or discoloration by/through review date. Will show signs of healing and remain free from infection by/through review date [Created: 03/31/25; Target date: 03/10/26]. Interventions included Administer protein supplements as ordered; Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing at least weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report declines to the MD; Inform family/caregivers/MD of any new area of skin breakdown; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Requires a cushion to wheelchair or Geri chair when sitting up; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; Requires the use of an air mattress; and Wound care MD consult PRN [Approach Start Date: 03/10/25; Created: 03/31/25]. [Resident #1] was at risk of pressure ulcer/injury due to friction and shear [Date initiated: 04/01/25]. Care plan goals indicated will have intact skin, free of redness, blisters or discoloration through the next review date [Initiated: 04/01/25; Target date 5/11/25]. Interventions reflected Minimum of 2 people plus draw sheet to lift [Resident #1] while in bed. [Date initiated: 04/01/25]. [Resident #1] had a pressure ulcer/injury. [Date initiated: 04/01/25]. Care plan goals indicated [Resident #1] will show no signs or symptoms of skin breakdown due to refusal to wear heel protectors through the next review date [Initiated: 04/01/25]. Interventions/tasks reflected Monitor and report re-emergence of skin breakdown secondary to resisting care and Reiterate the purpose and advantages of treatment. A record review of Resident #1's Order Summary Report reflected: - Start Date 11/11/24: May have pressure relieving mattress. - Start Date 12/24/24: Weekly Skin Assessment to be done on Thursday during 6-2 shift. - Start Date 02/04/25: May have heel protectors to BLE. - Start Date 02/10/25: Wound consult for area to right foot. - Start Date 02/26/25: Bacitracin zinc (OTC) ointment; 500 unit/gram; thin layer; topical. Apply to reddened area on left thigh every shift for Rash and other nonspecific skin eruption. - Start Date 03/02/25: Apply skin prep to right foot every shift. - Start Date 03/02/25: Apply skin prep to right great toe every shift. - Start Date 03/09/25: Clean open area to left hip with normal saline or wound cleanser, pat dry, apply collagen and dry dressing. [D/C 03/10/25] - Start Date 03/09/25: Wound consult. - Start Date 03/10/25: wound treatment Special Instructions: Clean area to left hip with normal saline or wound cleanser, dry, apply calcium alginate and dry dressing 3xweek and PRN. - Start Date 03/10/25: wound treatment Special Instructions: Clean area to sacrum with normal saline or wound cleanser dry, apply calcium alginate and dry dressing 3x week and PRN. [D/C03/19/25] - Start Date 03/19/25: Clean area to right medial first toe with normal saline or wound cleanser, dry, apply ansept and dry dressing 3 times a week and PRN. - Start Date 03/19/25: Clean area to right medial foot with normal saline or wound cleanser, dry, apply ansept and dry dressing 3 times a week and PRN. - Start Date 03/19/25: Clean area to sacrum with normal saline or wound cleanser, dry, apply ansept dry dressing 3 times a week and PRN. A record review of Resident #1's March 2025 MAR reflected RN B signed off that a weekly skin assessment was performed on Thursday, 03/06/25. Treatment orders for skin prep to right foot and great toe entered on 03/02/25. Treatment orders for the right foot, left hip, and sacrum were entered to begin on 03/10/25. Treatment orders were initialed that indicated care was provided as scheduled. Record review of Resident #1's completed Weekly Skin Assessments reflected: Date: Thursday, 02/07/25. Completed by LVN D. A large blood blister noted on the right side of the right big toe. Bruise noted on top of the right big toe. Date: Thursday, 02/13/25. Completed by LVN D. The blood blister on the right side of the toe is dry and purple. Bruise on top of right toe still visible. Date: Thursday, 02/20/25. Completed by LVN C. Treatment orders in place. No new skin integrity issues. Date: Thursday, 02/27/25. Completed by LVN E. Redness to left hip, wound care nurse notified, and Zinc has been applied. No further issues noted. Date: Thursday, 03/06/25. No Weekly Skin Assessment Form completed. Date: Thursday, 03/09/25 at 1:29 PM. Completed by LVN A. Eschar noted to left hip and abrasion/wound reopened right below the necrotic area. Date: Thursday, 03/09/25 at 10:39 PM. Completed by ADON I. [Resident #1] with open area to left hip, continues with wounds to blister noted on the right side of foot, the right big toe and on top of right great toe. Sacrum area with multiple skin pigmentation with dark color around areas. Date: Thursday, 03/13/25 at 8:38 AM. Completed by RN B identified wounds described as a Stage 2 sacrum, Stage 2 left hip, and Unstageable right lateral foot. Record review of Resident #1's hospice health aide visits notes revealed the following: On 02/07/25 at 09:28 AM the hospice health aide documented LVN D was notified about Resident #1's right foot that developed a deep tissue pressure area on the ball of the foot. On 02/26/25 at 03:33 PM the hospice health aide documented notification to nurse and directions received - [Resident #1] has a purple pressure area developed on left hip, staff applied skin protection, Resident #1 was repositioned. 02/28/25 at 02:57 PM the hospice health aide documented notification to nurse and directions received - [Resident #1] left hip has an open wound, staff nurse stated that she will apply Zinc to the area. Record review of Resident #1's progress notes reflected the following: LATE ENTRY on 02/13/25 at 11:15 AM (effective date 02/07/25 at 11:14 AM): LVN D wrote, A large blood blister noted on the right side of the right big toe. Bruise noted on top of the right big toe. Surrounding skin is dry, warm, and intact. Treatment nurse notified. The affected area was shown to [FM] in person. Will continue to monitor. On 02/10/25 at 7:57 PM, LVN C wrote, . Skin prep applied to discoloration on (Resident #1) right foot. Free from signs or symptoms of infection. Skin is unbroken and free of bleeding or drainage . On 02/26/25 at 2:05 PM, LVN E wrote, . Skin prep applied to discoloration on (Resident #1) right foot. Free from signs or symptoms of infection. Skin is unbroken and free of bleeding or drainage . On 03/02/25 at 2:00 PM, RN H wrote, . writer overheard Resident #1's RP talking on the phone with an angry tone. It appeared he was talking with the DON. The writer went into (Resident #1) room with ADON I to find out what the problem was. The RP was concerned that the blister to Resident #1 right foot had turned black . ADON I and supervisor went with the RP and assessed (Resident #1) blister, educated the RP that the blister was healing as expected. A recommendation was mad to have hospice come by and assess the blister and offer suggestions for further treatment if any . Record review of Resident #1's hospice RN visit note dated 03/02/25 at 6:00 PM revealed Dry blister to Right foot. No signs/symptoms of infection or pain. Patient comfortable during visit. Continued record review of Resident #1's progress notes reflected the following: On 03/03/25 at 6:09 PM, the WCN wrote, . Resident #1 continues to have a discoloration and swelling to feet area treated with skin prep and podus boots (applied to prevent and manage heel pressure and reduce pressure on the area). Area continues to be closed so no new treatment is warranted at this time. RP notified and reminded that Resident #1 was on hospice and other consults are not performed when this was the case. On 03/03/25 at 8:41 PM, LVN C wrote, . Skin prep applied to discoloration on (Resident #1) right foot. Free from signs or symptoms of infection. Skin is unbroken and free of bleeding or drainage . On 03/04/25 at 3:36 AM, RN H wrote, . Discoloration on right foot intact. No signs of infection noted . On 03/04/25 at 11:52 AM, RN B wrote, Resident #1 has a new order for skin prep to right great toe, skin prep applied, the area is clean, dry, skin intact. On 03/09/25 at 1:29 PM, LVN A wrote, RP called this nurse and ADON I to resident's room. RP states that the wound reopened. Upon assessing, abrasion/wound noted to left hip. minimal blood noted. Eschar noted to left hip and right below, skin reopened. cleansed area with NS, pat dry. applied collagen and dry dressing. skin assessment completed and wound care nurse made aware to eval and treat. On 03/09/25 at 10:47 PM, ADON I wrote, Upon head-to-toe skin assessment, resident noted with open area to left hip, dressing in place. Continues with blister to right side of foot, the right big toe and area on top of right great toe. Sacrum has multiple skin pigmentation areas, surrounded with dark color surrounding those areas, but skin is intact. No bruising noted to sacrum area. Skin intact underneath bilateral breast and abdomen areas. Resident with brown aging spot all over back area. Resident continues to be turned and repositioned every 2 hours. Podus boots in place. On 03/10/25 at 2:03 PM, RN B wrote, Upon incontinent care CNA (unidentified) reported opened area to sacrum with minimal bleeding no s/s of infection noted to the area, treatment nurse notified, treatment nurse notified, [RP] notified, treatment orders received, resident continues turning and repositioning every 2 hours, treatment nurse will be notified. On 03/10/25 at 2:33 PM, ADON I wrote, Treatment notified of new areas. Will wait for any orders. On 03/10/25 at 7:23 PM, the WCN wrote, Nurse rounded today and wound to left hip, sacrum, and right foot were assessed. Assessment performed by treatment nurse and new orders provided by MD. New orders noted in residents EHR, please refer to resident orders. Wound assessment updated. RP notified of new orders. On 03/11/25 at 1:45 PM, RN B wrote, Resident continues repositioning every 2 hours . wound care completed on open area to sacrum and open area to left hip . Record review of hospice physician visit and plan of care meeting notes, dated 03/17/25, revealed Resident #1 had a Stage II ulcer to the left lateral gluteal region. Eschar noted to medial aspect of right foot. During the plan of care meeting with the RP and facility staff, the hospice physician documented that the RP wished to maintain (Resident #1) comfort and dignity and wishes to forego aggressive interventions. Plan to continue with wound offloading and local wound care, facility wound care physician evaluation pending. Per the RP, understood that the patient would continue to have progressive wounds as it related to poor nutritional status, advanced disease, and multiple comorbidities. Record review of Resident #1's WMD visit reports dated 03/18/25 reflected the following: Date: Tuesday, 03/18/25 [Resident #1] presented with wounds on the right medial foot; left hip; sacrum; and right medial first toe. Left hip - unstageable (due to necrosis). Duration: greater than 5 days. Wound size (LxWxD): 4.1 x 1.5 x Not measurable cm. Depth was unmeasurable due to presence of nonviable tissue and necrosis. Surgical excisional debridement procedure performed. Right Medial First Toe - unstageable (due to necrosis). Duration: greater than 5 days.: Wound size (LxWxD): 2.4 x 1.5 x Not measurable cm. Depth was unmeasurable due to presence of nonviable tissue and necrosis. Right Medial Foot - Stage 4 Pressure Wound. Duration: greater than 5 days.: Wound size (LxWxD): 2.9 x 3.1 x Not measurable cm. Depth was unmeasurable due to presence of nonviable tissue and necrosis. Surgical excisional debridement procedure performed. Sacrum - Stage 3 Pressure Wound. Duration: greater than 5 days.: Wound size (LxWxD): 1.5 x 1.2 x 0.2 cm. Surgical excisional debridement procedure performed. Continued record review of Resident #1's WMD subsequent visit reports dated 03/24/25 and 03/31/25, revealed Resident #1 wounds were at goal or improved. On 03/24/25, the WMD performed surgical excisional debridement to the right medial foot and left hip. During a telephone interview on 04/06/25 at 12:05 PM, Resident #1's RP said that he noticed a reddened sore on Resident #1's right foot during a visit on 02/02/25. The RP said that he spoke with ADON I who replied that the sore was due to poor circulation. The RP said that during a visit on 03/02/25 he looked at the sore on Resident #1's right foot and it had turned purple with black areas. The RP said that ADON I said that the area on the foot would get worse before it got better. The RP said that he was not informed about Resident #1's left hip. On Sunday, 03/09/25, the RP said that Resident #1 complained of pain at the left hip. The RP said that he pulled back the brief to check, which was stuck to an undressed sore. The RP said that the sore seemed to have scabbed over at that point. The RP said that he called for the nurse and ADON I to come to the room and asked about the sore. The RP said that ADON I cleaned the wound and applied a dressing. During an interview and records review on 04/07/25 at 12:51 PM, RN B indicated that she was a new hire as of 03/03/25 and worked 6A - 2P shifts. RN B said that weekly skin assessments should be 7 days from the date of admission and the MAR would trigger the day the skin assessment was due and that was how she knew it needed to be completed. RN B said that she worked Thursday, 03/06/25, completed a skin assessment but did not know that she was supposed to complete a Weekly Skin Assessment form. RN B said that she performed the scheduled skin assessment on 03/13/25 and documented findings on the skin assessment form. RN B said that she documented the altered skin areas as the WCN described to the sacrum (Stage 2), left hip (Stage 2), and right foot (unstageable). During an interview on 04/07/25 at 2:43 PM, the WCN said that she performed wound care to residents with Stage 2 or larger wounds and performed rounds with the WMD every Tuesday. The WCN said that the charge nurses performed treatments to altered skin integrity like a rash, skin tear, or areas that required topical skin treatments. The WCN said that she or the WMD did not follow Resident #1 for wound care. The WCN said that she reviewed a weekly report that would reflect if a weekly skin assessment was not completed. The WCN said that she did not read the weekly skin assessment and expected the nurse to inform of any skin breakdown or changes observed during weekly skin assessments. The WCN said that the CNAs inspected the residents' skin for redness, bruising, or break in skin when assisting with showers, bed baths, and incontinent care. The WCN said that the CNAs should report any skin issues to the charge nurse. The WCN said that Resident #1 likely developed the pressure injury to the right foot because the heel protectors provided by hospice did not protect the whole foot. The WCN said that Resident #1 legs were contracted, and the feet pressed against each other. The WCN said that staff off-loaded pressure areas by turning and repositioning, with pillows, and position wedges. The WCN said that she became involved with Resident #1's skin management on or about 03/03/25, as reflected in Resident #1's progress notes, when she first learned about Resident #1's right foot in the morning meeting. The WCN said that she assessed and evaluated Resident #1's right foot that had discoloration and swelling. The WCN said that a purple or maroon discoloration could indicate a deep tissue pressure injury and could also present with a closed or ruptured blister. The WCN said the skin was not open. The WCN said that an immediate nursing intervention would be to prevent further damage and promote healing. The WCN said that staff were treating the area with skin prep and podus boots were applied to Resident #1's feet. The WCN reviewed the chart and said that she assessed and evaluated the discovered wound to Resident #1's left hip and notified the MD to obtain orders for treatment and a WMD consult on Monday, 03/10/25. During a telephone interview on 04/07/25 at 3:11 PM, the WMD said that he obtained permission from the RP before he performed surgical debridement to the wounds. The WMD said that the wounds overall condition was deteriorated to a degree but showed some progression with debridement and treatment. The WMD said that the wounds did not show any signs of infection. The WMD indicated that Resident #1 was a high risk for pressure ulcer development due to multiple disease processes, poor nutrition, and contractures. During an interview on 04/07/25 at 4:25 PM with ADON I said that once wounds were discovered, treatments were initiated on WMD rounds. An in-service was conducted related to turning and repositioning. ADON I said that Resident #1 received wound care every Monday, Wednesday, Friday, and PRN to right foot, left hip, and sacrum. ADON I did not recall when she first learned about wounds to Resident #1's hip and sacrum. ADON I said if she correctly recalled, the RP brought up concerns about the wound condition after RP removed dressing to Resident #1's left hip. The RP's said that the wound appeared to get worst and had a smell. ADON I said that she reassured the RP that the WCN was treating. ADON I denied the hip wound had an odor. ADON I did not recall the wound condition when she cleaned and covered with a dressing. During an interview on 04/18/25 at 3:34 PM, the DON said his expectation of skin management and pressure ulcer/injury prevention included weekly skin assessments to be completed every 7 days; CNAs to visualize the resident's skin on shower days and notify the charge nurse of any bruises, redness, sores, or any type of break in skin; off-loading and repositioning of residents as needed. The nurse must complete a weekly skin assessment form and initial the MAR that the skin assessment was completed. The DON said if a skin assessment was not document for one week, a resident's skin should still be checked during incontinent care, showers, and during random skin sweeps. The DON said that the discoloration to Resident #1's right foot/toe and left hip should have been monitored by the charge nurse for any changes or the need to notify the WCN. The DON said that ADON I ran weekly reports to determine if weekly skin assessments were completed. The National Pressure Ulcer Advisory Panel ([NPUAP], 2016) revised the definition and stages of pressure injury. Review of the new definition of suspected DTI is: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description is also given: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. (Reference: Edsberg LE, Black JM, [NAME] M, [NAME] L, [NAME] L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016; 43(6):585-597. doi:10.1097/WON.0000000000000281 https://pmc.ncbi.nlm.nih.gov/articles/PMC5098472/) The Centers for Medicare & Medicaid Services ([CMS], 2024), defined pressure ulcer/injury characteristics as: - Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI. - Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon, or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. (Reference: Centers for Medicare & Medicaid [CMS], State Operations Manual, Appendix PP. (Rev. 225; Issued: 08-08-24). F686 Skin Integrity, p. 298. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf Review of the facility's Skin Integrity Monitoring System policy and procedure, effective date 12/2018 indicated: Policy: It is the policy of this home that: 1) A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown; 2) A system will be in place to assure that all residents will be assessed and preventative measures will be in place to prevent the development of pressure injuries; and 3) A system will be in place to assure any type of skin conditions that do not constitute pressure injuries, will be monitored closely for any type of complications. Procedures included: Assessment and Monitoring 1) Braden Scale will be completed within 24 hours of admission / readmission and every week times 4 weeks for new admits/readmits; then quarterly and with any significant change in condition in software. 2) Residents will be screened daily through direct care provided and any deficits identified will be reported. 3) All residents will be assessed weekly using the Weekly Skin Assessment form for any type of skin integrity complications; this will include pressure injury and non-pressure related complications. 4) When a pressure injury or non-pressure skin deficit is identified, treatment orders are obtained from physician. 5) When a skin deficit is identified, dietary is to be notified . 6) When a skin deficit is identified, the Interdisciplinary Care Plan and the CNA Kardex (document that helps nursing staff organize and access key resident information for care/care planning) are to be updated to communicate [NAME] [TRUNCATED]

Based on observations, interviews, and record review the facility failed to establish and 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 one (Resident #1) of three residents observed for infection control. 1. The WCN failed to perform hand hygiene and change gloves during wound care for Resident #1. The failure could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #1's face sheet, dated 10/01/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease and cellulitis (skin infection) of left lower leg. Record review of Resident #1's Care Plan revealed she had a care plan for wounds. An observation and interview on 10/01/24 at 12:15 PM with the WCN revealed she was preparing to do wound care for Resident #1. The resident was awake, alert, and confused. She did not voice any concerns. The WCN performed hand hygiene, donned gloves and removed the dressing. She also placed a pad beneath the left foot. The WCN removed her gloves and performed hand hygiene. The resident had a healing ulcer on her left foot, directly beneath her first toe. The area was open and about the size of a quarter. The tissue was dark pink - red in color. The WCN cleaned the wound with 4x4 gauze and disposed of the soiled gauze onto the soiled pad beneath the resident's left foot. The WCN rolled up the soiled pad and placed it in the trash. The WCN did not change her gloves or perform hand hygiene. The WCN prepared the ordered treatment, applied it to the wound, and wrapped the wound and left foot. The WCN said she did not realize she did not change gloves or perform hand hygiene after cleaning the wound. She said it was important to perform hand hygiene in order to prevent infection transfer. An interview with the DON on 10/01/24 at 2:20 PM revealed staff were supposed to follow the facility policy for changing gloves and performing hand hygiene after cleaning a wound. The DON said the WCN was supposed to perform hand hygiene after cleaning the wound. He said hand hygiene was important after cleaning the wound to reduce transmission of pathogens harmful to the resident. Record review of the facility policy, Handwashing, dated December 2018, reflected: Policy It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection . Before and after direct resident contact . Before and after changing a dressing .

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Gnats were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections. Findings included: Observation on 05/28/24 at 9:17 a.m., revealed three gnats in the conference room crawling on the table. Observation on 05/28/24 at 9:39 a.m., revealed three gnats in the conference room flying round the surveyor. Observation on 05/28/24 at 9:40 a.m., revealed a gnat crawling across the nurse's station. Observation on 05/28/24 at 9:45 a.m., revealed a group of gnats flying down Hall 200. Observation and interview on 05/28/24 at 9:55 a.m., revealed a gnat crawling on the medication cart on Floor 200. Interview with LVN C revealed that this time of the year was bad for gnats. LVN C stated she did not see the pest control man at the facility. LVN C stated that the Administrator handles all of that, and that she had not reported the gnats to anyone. Observation and interview on 05/28/24 at 10:00 a.m., revealed a gnat crawling on the table, in the dining room on Floor 300. Observation on 05/29/24 at 10:05 a.m., revealed a gnat crawling on the table in the conference room. In an interview on 05/29/24 at 10:10 a.m., with Resident #129 revealed he see gnats every day when he goes to therapy, he stated he was new hear so he did not know really who to tell. Observation on 05/29/24 at 10:20 a.m., revealed a swarm of five gnats flying down the Hall 300. Observation on 05/29/24 at 10:22 a.m., revealed four gnats in room [ROOM NUMBER]B crawling on the bed linens. There were no residents in the room at this time. The residents were out in the hallway, neither of them stated they had seen any gnats. In an interview on 05/30/24 at 10:51 a.m., with Resident #43 revealed she had seen little black flying bugs and sometimes, in her room and on the hallways. The resident said she had not reported to anyone, and she did not recall seeing the pest man here. Observation and interview on 05/30/24 at 10:53 a.m., with Resident #3 revealed two gnats in the room and a gnat landed on the overbed table during the interview . Resident #3 said she had seen gnats around the facility every day, and she had lived there for about two months. She said she had not mentioned the gnats to anyone. Observation on 05/30/24 at 12:30 p.m., revealed a swarm of gnats (7) around a tray of food cart at the nurse's station on Floor 300. Observation and interview on 05/30/24 at 11:43 a.m., with Resident #32 revealed that he had seen more small black flies, he said he had not told anyone about the pest, he had just admitted this month, but he thought he had seen the pest control man there. During this interview two gnats were observed on the privacy curtain in the room. Observation on 05/30/24 at 12:07 p.m., revealed in room [ROOM NUMBER]B a fly crawling on the sheets while the resident was asleep in the bed. Observation on 05/30/24 at 12:17 p.m., revealed a gnat crawling on the upper arm of a resident, in Floor 300 dining room. The resident swatted at the gnat, the gnat began to crawl on the table, the resident did not notice the two gnats. The resident could not comment when ask about the gnats. Further observation revealed gnats on three different tables while food was being served in the Floor 300 dining room. Observation on 05/30/24 at 1:10 p.m., revealed a gnat crawling on the medication cart at the nurse's station. on Floor 200. Observation and interview on 05/30/24 at 1:12 p.m. revealed a pest control logbook at the nurse's station on Floor 200 and Floor 300. Observation and interview on 05/30/24 at 1:45 p.m. revealed LVN C on Floor 200 stated she was aware of the pest control logbook, she had never used the book, if she saw pest, she would tell the Maintenance man. Observation on 05/30/24 at 2:20 p.m., revealed a group of three gnats flying down Floor 200, one of the gnats landed on the door frame of a resident's room. Observation on 05/30/24 at 2:35 p.m., revealed a gnat crawling on the water container on the medication cart Floor 200. An interview on 05/30/24 at 3:05 p.m., with the Maintenance Supervisor revealed that he had worked at the facility for over three weeks. The Maintenance Supervisor stated he had seen gnats around the facility, and he tried to take care of them, but did not specify how. He stated the staff tells him when they see pest, but the staff does not use the pest control log at the nurse's stations. The Maintenance Supervisor stated he does not check the pest control logs at either one of the nurse's stations. He stated he had the ability to contact the pest control company that came one time a month for additional visits. The Maintenance Supervisor stated it could be upsetting to the residents to see gnats in their rooms and it could be annoying to the residents. Record review of the Pest control logs at the nurse's station on Floor 200 and Floor 300 dated 04/22 through 10/23 revealed no mention of gnats. There was no further documentation to review . Record review of facility provided pest control log revealed, in part, dates and treatments as follows: Treatment dates and services performed: 03-06-2024-after inspection verified active In the kitchen, we found numerous sanitation factors contributing to gnats and drain fly proliferation. An insecticide and insect growth regulator was utilized to knock down current populations. Drains were also targeted to help reduce further issues. It's recommended that the kitchen performs some type of heavy deep cleaning. On the exterior of the facility, an insect bait was utilized around the perimeter to form a barrier from common pests Will return as needed or in April. Thank you. 04-17-2024- today arrived to complete your April service. Upon arrival . checked in with the front desk and located the logbook. There were no new entry's for service in guest or common areas of the facility . then inspected the kitchen for gnats and found no new activity at this time . 05-02-2024 Today May service. Upon arrival . checked in with the front desk and located the logbook. There were no new entries for service in guest or common areas of the facility. I met with the new dietitian and part MD . gnats were reported . inspected the interior kitchen and found and small fly issue due to conducive conditions in dish pit area. Dietitian stated they will be doing a full deep clean this weekend spoke to admin about these issues, and we agreed to come out Tuesday for a small fly wipe down for kitchen area and adjacent hallway after breakfast. I did treat the affected areas and knocked down the population Record review of the facility's policy Pest Control Service Agreement dated December 2016 reflected, 1. SERVICES TO BE PERFORMED. Client hereby . provide the following services: a) Perform monthly pest control . Including: coordinating . staff to Implement an Integrated Pest Management Plan, monitor end track pest Issues inside and outside . addressing . Issues both reported and observed, recording actions taken and observations to staff to be kept on record. Pest control each month consists of; b) Inspecting and treating exterior pest Issues including [NAME] exits, potential entry points, and grounds. c) inspecting and treating Interior pest Issues Including kitchen, laundry, exits, closets. d) Monitoring and maintaining any equipment used to bait and/or eliminate pests inside and outside (I.e. fly fights and rodent bait stations). e) When requested, treat specific areas that are experiencing a particular problem, which may include the removal of persons In effected area for varying time periods, shall adequately suppress end/or treat the following as needed, . 4.1 Roaches (German/American/Brown-Banded) 4.2 Bed Bugs 4.3 Spiders/Scorpions 4.4 Crickets/Silverfish 4.5 Rodents 4.6 Flies/Goals/Fruit Flies 4.7 Wasps/Bees 4.8 Ants (Flre/carpenter/Black/Pharaoh/Odorous,etc) 4.9Tennttes .

Based on observation, interview, and record review the facility failed to establish and 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 6 of 7 (CNA A, CNA B, LVN C, CNA D, MA E, and MA F) staff members and 14 of 15 residents (Resident #3, #13, #22, #32, #43, #44, #46, #50, #64, #129, #130, #131, #132, & #150) reviewed for infection control procedures. CNA A, CNA B, LVN C, and CNA D failed to perform hand hygiene after direct contact with Residents #50, #22, #46, #132, #44, and #64 while serving meals on the hallways. MA E failed to disinfect the blood pressure cuff (machine used for checking blood pressure) in between blood pressure checks for Residents #130, #3, and #32. MA F failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #13 and #43. LVN C failed to wash her hands or use hand sanitizer after removing her gloves when using the glucometer machine (an instrument for measuring the concentration of glucose in the blood) between resident use, for Residents #131 and #132. This failure could place residents at risk for cross contamination and infections. Findings included : Record review of Resident #50's quarterly MDS assessment, dated 05/26/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included: chronic kidney disease (kidney work slow), hypertension (high blood pressure), and diabetes (high blood sugar). Resident #50 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #22's other payment MDS Assessment, dated 03/19/24, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: spinal stenosis (pain in the spine), hypertension (increased blood pressure), and osteoporosis (bone is deteriorating). Resident #22's, severely impaired for cognition and required one staff for assistance with activities of daily living. Record review of Resident #46's admission MDS Assessment, dated 05/01/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #46 had diagnoses which included: Diabetes (increased sugar levels). Resident #46 was cognitively able to make decisions and required one staff for assistance with activities of daily living. Record review of Resident #132's admission MDS Assessment, dated 03/15/24, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #132 had diagnoses which included: Diabetes (high blood sugar), Osteomyelitis (infection of the bone), and diastolic heart failure (the heart unable to pump blood correctly). Resident #132 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #44's other payment MDS Assessment, dated 04/09/24, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #44 had diagnoses which included: Diabetes (high blood sugar), and respiratory failure (lungs not able to work properly). Resident #44 was severely impaired for cognition cognitively and required assistance of two staff for activities of daily living. Record review of Resident #64's admission MDS Assessment, dated 05/21/24, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #64 had diagnoses which included: multiple rib fractures left side (broken ribs left side), lack of coordination (unable to mobilize safely), and unsteadiness on feet (not safe walking). Resident #64 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #130's admission MDS assessment, dated 05/26/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #130 had diagnoses which included: chronic pain (constant pain), chronic heart failure (heart's inability to pump blood through), and anxiety (nervousness). Resident #130 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #130's physician orders dated 05/20/24 reflected, Digoxin (heart failure) 1.25mg give one tab by mouth one time a day, Furosemide (for fluid buildup) 40mg give one tab by mouth one time a day, Lidocaine patch (for pain) 5% apply to back one time a day and to obtain blood pressure one time a day on each shift. Record review of Resident #3's other payor source MDS assessment, dated 04/26/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: hypertension (elevated blood pressure), chronic heart failure (heart's inability to pump blood through), and diabetes (high blood sugar). Resident #3 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #3's physician orders dated 05/10/24 reflected, Amiodarone (irregular heartbeat) 200 mg give one tab by mouth one time a day, Lasix (for fluid buildup) 40mg give one tab by mouth one time a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #32's admission MDS assessment, dated 05/20/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included: hypertension (elevated blood pressure), chronic heart failure (heart's inability to pump blood through), and diabetes (high blood sugar). Resident #32 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #32's physician orders dated 05/15/24 reflected, Amiodarone (irregular heartbeat) 200 mg give one tab by mouth one time a day, Metoprolol (high blood pressure) 25 mg give one tab by mouth one time a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #13's annual MDS assessment, dated 05/24/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included: essential hypertension (elevated blood pressure), tachycardia (fast, irregular heart rate), and diabetes (high blood sugar). Resident #13 was unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #13's physician orders dated 05/10/24 reflected, Diltiazem (high blood pressure) 120 mg give one tab by mouth one time a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #43's quarterly MDS assessment, dated 04/06/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had diagnoses which included: multiple sclerosis (nerve and muscle disease), and essential hypertension (high blood pressure). Resident #43 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #43's physician orders dated 05/10/24 reflected, Metoprolol (for high blood pressure) 25mg one tab by mouth one time a day, and to obtain blood pressure one time a day on each shift. Record review of Resident #131's admission MDS Assessment, dated 05/25/24, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #131 had diagnoses which included: Diabetes (high blood sugar), malignant neoplasm of bone (cancer of the bone), and pneumonia (infection of the lungs). Resident #131 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #131's physician orders dated 05/25/24 reflected, Humalog Kwik Pen subcutaneous solution pen-injector100 unit/ml (insulin) as sliding scale, before meals and at bedtime. Record review of Resident #132's admission MDS Assessment, dated 03/15/24, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #132 had diagnoses which included: Diabetes (high blood sugar), Osteomyelitis (infection of the bone), and diastolic heart failure (the heart unable to pump blood correctly). Resident #132 was cognitively able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #132's physician orders dated 05/05/24 reflected, insulin lispro insulin pen-injector100 unit/ml (insulin) as sliding scale, before meals and at bedtime. Observation on 05/28/24 at 10:20 a.m., revealed MA E performing morning medication pass, during which time she checked the blood pressure on Resident #130. MA E failed to sanitize the blood pressure cuff before or after using it on Resident #130. Observation on 05/28/24 at 10:34 a.m., revealed MA E performing morning medication pass, during which time she checked the blood pressure on Resident #32. MA E failed to sanitize the blood pressure cuff before or after using it on Resident #32. Observation on 05/28/24 at 10:51 a.m., revealed MA E performing morning medication pass, during which time she checked the blood pressure on Resident #3. MA E failed to sanitize the blood pressure cuff before or after using it on Resident #3. Observation on 05/28/24 at 11:00 a.m., revealed MA F performing morning medication pass, during which time she checked the blood pressure on Resident #13. MA F failed to sanitize the blood pressure cuff before or after using it on Resident #13. Observation on 05/28/24 at 11:38 a.m., revealed MA F performing morning medication pass, during which time she checked the blood pressure on Resident #43. MA F failed to sanitize the blood pressure cuff before or after using it on Resident #43. Observation on 05/28/24 at 12:03 p.m., revealed LVN C performed a blood sugar test on Resident #131. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) and then entered the room wearing gloves. LVN C did not wash her hands or use hand sanitizer after removing gloves. Observation on 05/28/24 at 12:05 p.m., revealed LVN C performed a blood sugar test on Resident #132. LVN C sanitized the glucometer machine (an instrument for measuring the concentration of glucose in the blood) and then entered the room wearing gloves. LVN C did not wash her hands or use hand sanitizer after removing gloves. Observation on 05/28/24 beginning at 12:30 p.m., revealed CNA A, CNA B, LVN C, and CNA D had walked down the hallway, did not use hand sanitizer, and served a lunch tray to Residents #11, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #50, , Resident #22, Resident #46, Resident #132, Resident #44, and Resident #64. Each staff member prepared the meal tray for the resident to eat their lunch. The CNAs and LVN did not have on gloves. The CNAs was observed to not wash their hands or use hand sanitizer, available in the hallway. Observation on 05/28/24 beginning at 12:40 p.m., CNA A, CNA B and CNA D was observed to enter the east end of Floor 200 to serve lunch trays. The CNAs opened the tray service cart and started to pull trays without washing hands or using hand sanitizer. The DON approached the staff and instructed them to all use hand sanitizer prior to and between meal service. An interview on 05/28/24 at 10:55 a.m., MA E stated she did not think about cleaning the blood pressure cuff between usage. MA E stated she wore gloves between each usage when she took the blood pressure and used hand sanitizer, but she did not think the cuff needed to be cleaned. MA E stated if the cuff was on the residents and then not cleaned it could spread germs to others. An interview on 05/28/24 at 11:45 a.m., MA F stated she did not think about cleaning the blood pressure cuff between usage. MA F stated she knew she was supposed to use the sanitizing wipes between each usage when she took the blood pressure, but she did not think about it. MA F stated if the cuff was not cleaned appropriately, it could spread germs to others. An interview on 05/28/24 at 1:45 p.m., CNA A stated he did not complete hand hygiene after having direct contact with residents. CNA A stated he was supposed to use the hand sanitizer in between serving each tray and wash hands with soap and water after the third tray from the hall cart. CNA A said he had been educated on completing hand hygiene. CNA A stated he did not sanitize his hands, because he was nervous and trying to get the lunch trays served before the food got cold. An interview on 05/28/24 at 2:45 p.m., LVN C revealed the nurses checked the meal tickets to make sure they are the correct diet being served to the resident. LVN C stated she was trying to help serve the trays so that food did not get cold, and she did not think about the hand sanitizer, since it was not direct resident care, it was just moving the overbed table and setting up the tray for them. Further interview with LVN C revealed she thought if she wore gloves for all her blood sugar checks she was protecting herself and the residents from spreading any germs because she was changing her gloves every time, between each blood sugar check and when she cleaned her glucometer. An interview with the DON on 05/30/24 at 2:00 p.m., revealed that all staff must complete hand hygiene after having contact with residents. He stated CNAs and LVNs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray and on the third tray they are to use soap and water and wash their hands. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. Record review of an undated in-service log revealed CNA A, CNA B, LVN C, and CNA D received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted on 05/15/24 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands after every third use of hand sanitizer. Record review of the Facility's Policy titled Infection control dated December 2018 reflected: 1. all personnel shall be trained be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections 2. all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to, other personnel, residents, and visitors 5. Employees must wash their hands c. before and after direct resident contact g. before and after assisting a resident with meals Record review of the Facility's Policy titled Infection control-Cleaning and Disinfecting Resident Care items and Equipment dated December 2018 reflected: It is the policy of this home to clean and disinfect resident-care equipment, including reusable items and durable medical equipment . non critical items are those that come in contact with intact skin but not mucous membranes . non-critical resident-care items include bedpans, blood pressure, cuffs

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 8 residents (Resident #'s 45, 18, 17, 9, and 67) reviewed for accommodation of needs, in that: The facility failed to ensure: Residents #'s 45, 18, 17, 9, and 67 had either unwanted facial hairs (Resident #'s 45, 18, and 17 female residents) and or long, dirty, or untrimmed nails (residents #'s 9 and 67). This failure placed residents at risk of not receiving services/care with reasonable accommodation of their needs and preferences, feelings of not being listened to, and depression. Findings include: Record review of Resident # 45's Face Sheet revealed the resident had an original admitted [DATE] with diagnoses which included Cellulitis of right lower limb (Primary, Admission), Cough, unspecified, Acute respiratory failure with hypercapnia (elevated levels of Carbon Dioxide in the blood), Unspecified diastolic (congestive) heart failure. Record review of Resident # 45's MDS dated [DATE] reflected a BIMS score of 15 out of 15, which suggested no cognitive impairment (no difficulty making decisions that affected everyday life and care). Continued review showed substantial/maximal staff assistance for daily care, including personal hygiene. Record review of Resident 45's Care Plan dated 4/16/24 read, in part, [Resident #45] has an ADL self-care performance deficit and requires assistance by staff in all Activities of Daily Living (ADL's), 2 staff members for bed mobility and toileting, 1 staff member for transfers, bathing, dressing, grooming, personal hygiene. Eating with set up tray assist. During an observation in the dining room on 5/29/24 at 12:03 PM, Resident # 45 was sitting up in motorized wheelchair at the dining table. Resident #45's wheelchair was observed to have a frayed right armrest, the resident appeared to have facial hair on and below her chin. She stated that she had noticed that it was frayed and that she would like it to be repaired but did not know who to tell about it. She stated that it did not seem to bother her skin yet. She stated that she had not been told about having facial hair but would very much like it to be shaved off. Record review of Resident # 18's Face sheet revealed the resident had an original admitted [DATE] with diagnosis of Encephalopathy (disorder that affects structure or function of brain), unspecified (Primary, Admission), Cauda equina syndrome (compression of nerves at base of spine), Muscle wasting and atrophy, not elsewhere classified, unspecified site, Muscle weakness (generalized), Cognitive communication deficit. Record review of Resident # 18's MDS dated [DATE] reflected a BIMS score of 12 out of 15, which suggested moderate cognitive impairment. Continued review showed substantial/maximal staff assistance for daily care, including personal hygiene. Record review of Resident # 18's Care Plan dated 5/21/24 read in part, that [Resident #18] has an ADL self-care performance deficit and requires assistance by staff in all Activities of Daily Living (ADL's), 2 staff members for bed mobility and toileting, 1 staff member for transfers, bathing, dressing, grooming, personal hygiene. Eating with set up tray assist. During an observation and interview on 5/28/24 at 10:56 AM, Resident # 18 was observed to be sitting comfortably in a wheelchair, the left armrest on the wheelchair appeared to have cracked and half of the armrest cushion appeared to be missing entirely. The resident's nails appeared to be long and tinged yellow with some dirt under them. The resident stated that he did not like to have long nails and that he wished someone would trim them more often for him. Record review of Resident # 17's Face Sheet revealed the resident had an original admitted [DATE] with diagnoses which included Interstitial pulmonary disease (progressive scarring of the lung tissue), unspecified (Primary, Admission), Urinary tract infection, other speech and language deficits following cerebral infarction, Pneumonia, Acute upper respiratory infection. Record review of Resident # 17's MDS dated [DATE] reflected a BIMS score of 00 out of 15, which suggested severe cognitive impairment. Continued review showed total/maximal staff assistance for daily care, including personal hygiene. Record review of Resident 17's Care Plan dated 5/07/24 read, in part, [Resident #17] has an ADL self-care performance deficit and requires assistance by staff in all Activities of Daily Living (ADL's), 2 staff members for bed mobility and toileting, 2 staff member for transfers, bathing, dressing, grooming, personal hygiene. During an observation and interview of on 5/28/24 at 11:13 AM, Resident #17 was observed to have untrimmed, long nails on both hands, the nails appeared to have some dirt accumulation under them. The resident was unable to respond to questions. During the observation of Resident # 17, CNA H entered the room and stated that Resident #17's nails should have been trimmed, she stated that she had seen Resident # 17's nails longer. She denied that the resident or his family had any objection or instructions to keep Resident #17's nails long or untrimmed. She stated that she would trim Resident # 17's nails later that evening when she would administer a bed bath for the resident. Record review of Resident # 9's Face sheet revealed the resident had an original admitted [DATE] with diagnoses of Cerebral palsy, unspecified (Primary, Admission), Diarrhea, Urinary tract infection, site not specified, Depression, Anxiety disorder due to known physiological condition. Record review of Resident # 9's MDS dated [DATE] reflected a BIMS score of 07 out of 15, which suggested severe cognitive impairment. Continued review showed total/maximal staff assistance for daily care, including personal hygiene. Record review of Resident # 9's Care Plan dated 5/07/24 read, in part, [Resident #9] Requires extensive assist of 1 staff member for all ADL functions except eating with set up tray assist. Set-up, assist, give shower, shave, oral, hair, nail care per schedule and PRN. During an observation and interview on 5/29/24 at 12:40 PM, Resident # 9 was observed to have facial hair on her chin, she stated that it would be nice if someone would help her with her chin hairs because she would never want to have them. She stated that none of the staff had mentioned that she had any chin hairs. Record review of Resident # 67's Face sheet revealed the resident had an original admitted [DATE] with diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (Primary), Depression, unspecified, Gastro-esophageal reflux disease without esophagitis (chronic heart burn). Record review of Resident # 67's MDS dated [DATE] reflected a BIMS score of 08 out of 15, which suggested moderate cognitive impairment. Continued review showed minimal staff assistance for daily care, including personal hygiene. Record review of Resident # 67's Care Plan dated 4/24/24 read, in part, [Resident #67] Requires minimal assist of 1 staff member for all ADL functions. ADLs Functional Status/Rehabilitation Potential Residents ADL Functions: Bed Mobility: assist x 1, Transfers: assist x 1, Dressing: assist x 1, Eating: assist x 1, Toileting: assist x 1, Personal Hygiene: assist x 1, Bathing: assist x 1. Assist, give-- shower, shave, oral, hair, nail care per schedule and as needed. During an observation and interview on 5/28/24 at 3:01 PM, Resident #67 was observed to have very long toenails and facial hair consisting of several long hairs on and below her chin. She stated that she thinks a podiatrist came around last month but she was not entirely sure, she stated that she didn't know who to ask to shave off her facial hair but that she did not want facial hair and hoped a staff member could help her with getting rid of the chin hairs. In an interview on 5/30/24 at 3:20 PM with the DON, he stated that residents should have their nails trimmed and female residents should always be offered to have any unwanted facial hair shaved off for them. Long nails could cause injury to residents and male residents may find it embarrassing to have long nails. Female residents should have unwanted facial hair attended too, as having unwanted facial hair could cause the residents emotional harm or embarrassment. Record review of the facility's policy titled Activities of Daily Living dated December 2018, reflected in part .it is the policy of this home to assure residents have their activities of daily living met .Grooming: Encourage residents with nail trimming and grooming .assist residents with shaving .makeup application.

Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility reviewed for QAPI. The facility failed to maintain documentation of QAPI meetings prior to June of 2024. This failure placed residents at risk of maintaining and improving safety and quality of life. Findings included: Record review of QAPI meetings revealed: Facility had maintained QAPI meeting minutes from 08/2023 to 02/2024. No signed QAPI team signature sheets were found from 03/2024 to 05/2024. During an interview on 05/29/24 at 1:30 PM, the ADM stated he and the staff had been scouring the ADM office for evidence of previous QAPI meetings with no success. He said he became the temporary ADM in May of 2024, and his staff was unable to locate where the former ADM had placed the meeting minutes or signature sheets. During an interview on 05/30/24 at 1:24 PM, the ADM said that he and the staff was unable to locate any other QAPI documented meetings after Feb of 24 and that he did not have any proof that meetings occurred or were fully attended for the last three months. He stated that without monthly meetings the facility would not be alert to problems and not be able to create resolutions or assess problems and the effectiveness of solutions . Record review of QAPI policy dated 1/12/2027 revealed: The facility will conduct monthly meetings to monitor and evaluate all areas of facility services and practices . Establish systems and processes to maintain documentation relative to the QAPI program, as a basis for demonstrating that there is an effective ongoing program .All attending team members will sign in on the attached sheet at each meeting.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for four (Resident #130, #32, #3, and #43) of eight residents administered medications by MA E and MA F reviewed for significant medication errors . MA E failed to administer Eliquis (blood thinner) on 05/28/24 as ordered by the physician for Resident's #130, #32, and #3. MA F failed to administer Resident #43's Eliquis 5mg on 05/28/24 as ordered by the physician. This failure placed residents who were ordered to receive blood thinner at risk of not receiving their medications as ordered by the physician, resulting in blood clot and clinical complications. Findings included: Record review of Resident #130's admission MDS assessment, dated 05/26/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #130 had diagnoses which included: chronic pain (constant pain), chronic heart failure (heart's inability to pump blood through), and anxiety (nervousness). Resident #130 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Observation on 05/28/24 at 10:20 a.m., revealed MA E administered the following medication to Resident #130 including Eliquis 2.5mg. Record review of Resident #130's physician orders dated 05/20/24 reflected, Eliquis (blood thinner) 2.5mg give one tab by mouth BID (two times a day at 9:00 a.m. and 5:00 p.m .) Interview with Resident #130 on 5/28/24 at 1:29 p.m., revealed Resident #130 stated she received her Eliquis medication at different times of the day, sometimes it was early in the morning and sometimes it was later in the morning like today and she was concerned about blood clotting . Resident #130 stated she had not told anyone. Interview on 05/28/24 at 1:32 p.m., MA E stated she told Resident #130 that she was running behind this morning, because of the weather, and that her Eliquis medication was given with the other medications, that she was supposed to give it around 9:00 a.m. MA E stated Eliquis was for preventing clots, almost everyone here is on some kind of blood thinner. MA E stated she was unaware of anything concerning a medication error report concerning time . Review of Resident #130's MAR dated 05/01/24 reflected the following: On 05/28/24 at 10:20 a.m., Resident #130's Eliquis 2.5mg (blood thinner) was administered late, and its scheduled time was 9:00 a.m. (Resident #130 received her medications at 10:20 a.m.) The MAR had it documented under the option of other, indicating the documentation was late. Record review of Resident #32's admission MDS assessment, dated 05/20/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included: hypertension (elevated blood pressure), chronic heart failure (heart's inability to pump blood through), and diabetes (high blood sugar). Resident #32 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Observation on 05/28/24 at 10:34 a.m., revealed MA E administered the following medication to Resident #32 including Eliquis 5 mg. Record review of Resident #32's physician orders dated 05/15/24 reflected, Eliquis (blood thinner) 5 mg give one tab by mouth BID (two times a day) at 9:00 a.m. and 5:00 p.m. Review of Resident #32's MAR dated 05/01/24 reflected the following: On 05/28/24 at 10:32 a.m., Resident #32's Eliquis 5mg (blood thinner) was administered late, and its scheduled time was 9:00 a.m. Further documentation of the MAR reflected the late documentation was under other indicating the documentation was late. Record review of Resident #3's other payor source MDS assessment, dated 04/26/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: hypertension (elevated blood pressure), chronic heart failure (heart's inability to pump blood through), and diabetes (high blood sugar). Resident #3 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Observation on 05/28/24 at 10:51 a.m., revealed MA E administered the following medication to Resident #3 including Eliquis 5mg . Record review of Resident #3's physician orders dated 05/10/24 reflected, Eliquis (blood thinner) 5mg give one tab by mouth BID (two times a day), at 9:00 a.m. and 5:00 p.m. Review of Resident #3's MAR dated 05/01/23 reflected the following on 05/28/24 at 10:51 a.m., Resident #3's Eliquis (blood thinner) was administered late, and its scheduled time was 9:00 a.m. (Resident #3 received her medication at 10:51 a.m.). Record review of Resident #43's quarterly MDS assessment, dated 04/06/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43 had diagnoses which included: multiple sclerosis (nerve and muscle disease), and essential hypertension (high blood pressure). Resident #43 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Observation on 05/28/24 at 11:38 a.m., revealed MA F administered the following medication to Resident #43 including Eliquis 5mg. Record review of Resident #43's physician orders dated 05/10/24 reflected, Eliquis (blood thinner) 5mg one tab by mouth BID (two times a day) at 9:00 a.m. and 5:00 p.m. Review of Resident #43's MAR dated 05/01/24 reflected the following: On 05/28/24 at 11:38 a.m., Resident #43 Eliquis (blood thinner) 5mg was administered late, and its scheduled time was 9:00 a.m. (Resident #43 received her medications at 11:38 a.m.). Interview with Resident #43 on 5/28/24 at 1:39 p.m., revealed Resident #43 stated she received her Eliquis medication at different times of the day, it is usually almost lunch time on most days like today and she was concerned about blood clotting . Resident # 43 stated that she had not reported to any one, she just took the medications when they brought them to her. In an interview on 05/28/24 at 1:45 p.m., MA F revealed she knew what the time frame was for the medications that had been ordered, but sometimes it was impossible to give them during that time frame because the resident did not want at that time, they were in the shower, they were in therapy, so they get their medications when they want them. MA F stated she had not communicated this to the charge nurse, or the DON. MA F stated Eliquis was for preventing blood clots. MA F stated if you give medications wrong you are supposed to report to the charge nurse. She said she had not done that she was giving the medications when she could. Interview with the DON on 05/30/24 at 2:50 p.m., revealed he had worked at the facility for six months. The DON stated he expected to be notified from all med aides and nurses if medication was given late. The DON stated all medications to the resident per physician order was to prevent the residents from complications including prevent blood clot from missing Eliquis. The DON stated there is policy medications that are given late, they should be reported as a medication error to me. The DON stated he would be in-serving on the appropriate way to perform a medication pass and when to communicate with him concerning, problems related to the medication pass. Review of the facility's policy on Medications-Unusual Occurrences, dated December 2018, revealed, It is the policy of this home to administer medications within the standards of practice . A medications error occurs when a medication is administered in any manner that is inconsistent with the physician's order for the medication. Medication errors include , but not limited to administering the wrong medication, administering at the wrong time

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for 10 of 80 opportunities during medication pass resulting in an 12 percent (12%) error rate for 5 (Residents #130, #32, #3, #13, and #43) of 8 residents observed for medication pass . 1. MA E failed to administer Resident #130's Potassium 20 meq ( potassium supplement) and Eliquis 2.5mg (blood thinner) in a timely manner. 3. MA E failed to administer Resident #32's Eliquis 5mg (blood thinner) in a timely manner. 4. MA E failed to administer Resident #3's Eliquis 5mg (blood thinner) and Prostat 30ml (protein supplement for wound healing) in a timely manner. 6. MA F failed to administer Resident #13's Carbi/dopa [NAME] doppa 10mg/100mg (for Parkinson diseases) and Ropinirole 0.25mg (restless) in a timely manner. 8. MA F failed to administer Resident #43's Baclofen 5mg (muscle relaxer), Eliquis 5mg (blood thinner), and Lyrica 150mg in a timely manner. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a decreased health status. Findings included : Observation on 05/28/24 at 10:20 a.m., revealed MA E administered the following medication to Resident #130 Potassium 20 meq and Eliquis 2.5mg. Review of Resident #130's Physician's Order dated 09/27/18 and updated 05/08/24 reflected, Potassium 20 meq one three times a day at 9:00 a.m.,1:00 p.m. and 5:00 pm. Observation on 05/28/24 at 10:34 a.m., revealed MA E administered the following medication to Resident #32 Eliquis 5 mg. Review of Resident #32's physician's order dated 05/28/24 reflected Eliquis 5 mg 1 PO QD at 9:00 a.m. Observation on 05/28/24 at 10:51 a.m., revealed MA E administered the following medications to Resident #3, Eliquis 5mg and prostat liquid 30 mg . Review of Resident #3's physician's order dated 05/01/24 reflected the following: Eliquis 5mg 1 tab PO at 9:00 a.m. and 5:00 p.m. and prostat liquid protein 30 ml BID at 9:00 a.m. and 5:00 p.m. Observation on 05/28/24 at 11:00 a.m., revealed MA F administered the following medications to Resident #13, Carbidopa levodopa 10mg/100mg and Ropinirole 0.25mg. Review of Resident #13's physician orders dated 05/01/24 reflected the following: Carbidopa levodopa 10mg/100mg BID at 8:00 a.m. and 4:00 p.m. and Ropinirole 0.25mg TID at 8:00 a.m., 12 :00 p.m., and 4:00 p.m. Observation on 05/28/24 at 11:38 a.m., revealed MA F administered the following medications to Resident #43, Baclofen 5mg and Lyrica 150 mg and Eliquis 5mg. Resident #43's physician orders dated 05/01/24 reflected the following: Baclofen 5mg TID at these times 9:00 a.m.,1:00 p.m., and 5:00 pm and Lyrica 150mg TID at 9:00 a.m., 1:00 p.m., and 5:00 p.m. In an interview on 05/30/24 at 2:00 p.m., the DON revealed the staff have an hour before and after the administration time if given later it is considered late. The DON stated the staff should be giving the medications at the time they are ordered, if the staff is unable to give the medications timely, they are not communicating with me about it. The DON stated, the medication aides, and the nurses have plenty of time to let me know these things. In an interview at 05/28/24 at 11:15 a.m., MA E revealed she knew she had an hour before and after the ordered administration time, it was impossible sometimes to get them all their medications within the two-hour time frame. MA E stated sometimes I have to come back because the therapist is there working with them in the room, or the resident does not want the medication at that time. MA E stated she had not reported that she had problems sometimes giving the medications timely. In an interview on 05/28/24 at 11:45 a.m., MA F revealed she knew what the time frame was for the medications that had been ordered, but sometimes it was impossible to give them during that time frame because the resident did not want at that time, they were in the shower, they were in therapy, so they get their medications when they want them. MA F stated she had not communicated this to the charge nurse, or the DON . Review of the facility policy and procedure Medication Administration dated December 2018 reflected, It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician

Based on observation, interview, and record review the facility failed to post the following information on a daily basis: (1) Current date. (2) The total number and the actual hours worked by Register Nurses, Licensed Vocational Nurses, Certified nurse's aides, and Resident census at the beginning of each shift in a prominent place readily accessible to residents and visitors. The facility did not post and maintain the required staffing information from May 23, 2024, to May 28, 2024. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily. Findings include: During an observation on 05/28/24 at 9:49 AM, Nursing Staffing Information dated 05/23/24 was posted up in the facility main entrance visible to all residents and visitors. In an interview on 05/28/24 at 9:50 AM, the ADM stated that hours should be posted so that both family members and residents are aware of how many staff might be in the building during each shift. Without that information, residents and visitors may feel that there are not enough staff to sufficiently care for their loved ones . Policy review of a document dated 12/2017 entitled Nursing Policy and Procedure, Posting Nurse Staff Information and Report revealed that It is the policy of this home to post staff information daily.the nurse staffing data must be posted at the beginning of each shift.

Based on observations, interviews, and record review, the facility failed to ensure all assistive devices and overbed tables were maintained and free of hazards for three (Residents #9, #18, and #45) of eight residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #9, #18, and #45. These failures could place residents at risk for equipment that was in unsafe operating condition, which could cause injury. Findings included: Record review of Resident # 9's Face sheet revealed the resident had an original admitted [DATE] with diagnosis of Cerebral palsy, unspecified (Primary, Admission), Diarrhea, Urinary tract infection, site not specified, Depression, Anxiety disorder due to known physiological condition. Record review of Resident # 9's MDS dated [DATE] reflected a BIMS score of 07 out of 15, which suggested severe cognitive impairment. Continued review showed total/maximal staff assistance for daily care, including use of a wheelchair. Record review of Resident # 9's Care Plan dated 5/07/24 read, in part, [Resident #9] Requires extensive assist of 1 staff member for all ADL functions. Resident requires a wheelchair, Resident sleeps in the wheelchair with bedside table in front of her with a pillow on top. During an observation and interview on 5/29/24 at 12:40 PM, Resident # 9 was observed to have a frayed and cracked armrest on the right side of her wheelchair. Resident #9 stated that she sleeps in her wheelchair and is in it nearly all day and that it would be nice to have a new arm rest to replace the broken one. Record review of Resident # 18's Face sheet revealed the resident had an original admitted [DATE] with diagnoses of Encephalopathy (disorder that affects structure or function of brain), unspecified (Primary, Admission), Cauda equina syndrome (compression of nerves at base of spine), Muscle wasting and atrophy, not elsewhere classified, unspecified site, Muscle weakness (generalized), Cognitive communication deficit. Record review of Resident # 18's MDS 5/09/24 reflected a BIMS score of 12 out of 15, which suggested moderate cognitive impairment. Continued review showed substantial/maximal staff assistance for daily care, including use of a wheelchair. Record review of Resident # 18's Care Plan dated 5/21/24 read in part, that [Resident #18] has an ADL self-care performance deficit and requires assistance by staff in all Activities of Daily Living (ADL's), 2 staff members for bed mobility and toileting, 1 staff member for transfers, bathing, dressing, grooming, personal hygiene. Transfers to and from wheelchair. During an observation and interview on 5/28/24 at 10:56 AM, Resident # 18 was observed to be sitting comfortably in a wheelchair, the left armrest on the wheelchair appeared to have cracked and half of the armrest cushion appeared to be missing entirely. Resident #18 stated that he didn't think that he had not suffered any scratches from the missing part of the armrest on his wheelchair, but that it may be more comfortable if it was replaced. Record review of Resident # 45's Face Sheet revealed the resident had an original admitted [DATE] with diagnoses which included Cellulitis of right lower limb (Primary, Admission), Cough, unspecified, Acute respiratory failure with hypercapnia (elevated levels of Carbon Dioxide in the blood), Unspecified diastolic (congestive) heart failure. Record review of Resident # 45's MDS dated [DATE] reflected a BIMS score of 15 out of 15, which suggested no cognitive impairment (no difficulty making decisions that affected everyday life and care). Continued review showed substantial/maximal staff assistance for daily care, including personal hygiene. Record review of Resident 45's Care Plan dated 4/16/24 read, in part, [Resident #45] has an ADL self-care performance deficit and requires assistance by staff in all Activities of Daily Living (ADL's), 2 staff members for bed mobility and toileting, 1 staff member for transfers, bathing, dressing, grooming, personal hygiene. Eating with set up tray assist. During an observation in Resident # 45 in the dining room on 5/29/24 at 12:03 PM, Resident # 45 was sitting up in motorized wheelchair at the dining table. Resident 45's wheelchair was observed to have a frayed right armrest. She stated that she really hadn't noticed but that it would be nice to have a new armrest for her chair. In an interview on 5/30/24 at 3:05 PM, the Maintenance Supervisor stated that he was responsible for the repair of wheelchairs and if the residents needed other equipment replaced. He stated he kept a maintenance logbook at the nurse's station, but the staff tell him, they do not use the book. The Maintenance Supervisor stated he had not had any staff members tell him about any wheelchairs needing repair. The Maintenance Supervisor stated that if the equipment was not in working ordered it could cause injuries. In an interview 05/30/24 3:20 PM, the DON stated that armrests on wheelchairs that were damaged or missing could cause skin degradation for the resident and that wheelchair armrests should be repaired at all times for the comfort and safety of the residents. Record review of the Maintenance log dated 1/01/2024 through 5/30/2024 at the nurse's station, reflected no entries for wheelchair armrest repair. A review of the facility's policy and procedure Adaptive Devices and Equipment dated December 2022 reflected Policy Statement Our facility maintains and supervises the use of assistive devices and equipment for residents . 6. The following factors and addressed to the extent possible to decrease the risk of available accidents associated with devices and equipment . c. Devices condition-devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 5 (Residents #16, #13, #26, #18 and #45) of 10 residents observed in the dining room for dignity. A. Activity Coordinator A was observed standing next to seated Resident #16 and Resident #13 while providing assistance with eating. B. ADON A was observed using a cell phone while sitting at the table with Resident #13 and Resident #26 that required assistance with eating. C. Resident #45 had exposed tubing from her wound vacuum-assisted closure device draped from her ankle, across the side of her wheelchair, to the machine on the back of the wheelchair while sitting at the table in the dining room during lunch. D. Resident #18 was eating their meal for over six minutes before Resident #13, who was sitting at the same table, was provided a tray. This failure placed residents at risk of experiencing diminished quality of life, loss of dignity, and could negatively affect their psychosocial well-being. Findings included: Record review of Resident #16's Face Sheet dated 05/31/24 revealed Resident #16 was [AGE] years old with diagnoses of Parkinson's disease, cognitive communication deficit, and dysphagia (difficulty swallowing). Record review of Resident #16's MDS dated [DATE] revealed Resident #16 required partial or moderate assistance (helper does less than half the effort) eating. Record review of Resident #16's Care Plan dated 04/16/24 stated Resident #16 should be offered tray set-up and verbal cueing while eating. Record review of Resident #13's Face Sheet dated 05/30/24 revealed Resident #13 was [AGE] years old with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Record review of Resident #13's MDS dated ,d+[DATE]/ 24 revealed Resident #13 requires one-person physical assistance while eating. Record review of Resident #13's Care Plan dated 02/27/24 revealed Resident #13 should be monitored for chewing and swallowing problems. Record review of Resident #26's Face Sheet dated 05/30/24 revealed Resident #26 was [AGE] years old with a diagnoses of dehydration, dysphagia (difficulty swallowing), and dementia (impaired memory). Record review of Resident #26's MDS dated [DATE] revealed Resident #26 required supervision with one-person physical assistance while eating. Record review of Resident #26's Care Plan dated 02/27/24 stated to provide hands on assistance during meals. Record review of Resident #45's Face Sheet dated 05/30/24 revealed Resident #45 was [AGE] years old with a diagnoses of anxiety, schizoaffective disorder (mental health disorder), and cognitive communication deficit. Record review of Resident #45's Care Plan dated 04/16/24 revealed the Resident #45 required treatment and interventions for the treatment of anxiety, depression, mood disorder, behavior management, schizophrenia. Observation on 5/28/24 at 12:10 p.m., Activity Coordinator A was standing between Resident #16 and #13 while assisting with eating their lunch. Observation on 5/29/24 at 12:24 p.m., ADON A was observed sitting at a table with Resident #26 and Resident #13. Resident #13 and Resident #26 stared at their plates and did not eat while ADON A looked down at a cell phone. ADON A swiped the cell phone screen with her thumbs for over two minutes before ADON A looked up and sat the cell phone in her lap. ADON A then assisted Resident # 26 by placing silverware in the resident's hand and cued Resident #13 to take a bite of food. Observation on 5/29/24 at 12:42 p.m., ADON A was observed sitting at a table with Resident #26 and Resident #13. Resident #13 and Resident #26 stared at their plates and did not eat while ADON A looked down at a cell phone. Observation on 5/30/24 at 12:12 p.m., Resident #45 was observed sitting at a dining room table and had exposed tubing from her wound vacuum-assisted closure device draped from her ankle, across the side of her wheelchair, to the machine on the back of the wheelchair. Fluids were visible going through tubing to the machine. Observation on 5/30/24 at 12:12 p.m., Resident #18 was observed eating for over six minutes before Resident #13 was provided a tray. Observation on 5/30/24 at 12:18 p.m., Activity Coordinator A was observed standing next to seated Resident #13 while assisting Resident #13 with eating. In an interview on 5/30/24 at 12:15 p.m., Activity Coordinator A reported Resident #13's tray was on another warming cart and would be brought to the resident when the cart arrives. In an interview on 5/30/24 at 12:32 p.m., Activity Coordinator A stated everybody at a table should be served at the same time. Activity Coordinator A stated she was unsure if she should have waited until Resident #13's tray arrived to serve Resident #18. Activity Coordinator A stated she was unsure if Resident #45 always had wound VAC tubing exposed or if it should be covered but would ask the nurse. In an interview on 5/30/24 at 12:34 p.m., ADON A stated they should try to keep wound VAC tubing as private as possible and use a privacy bag for the machine. ADON A stated the wound VAC machine did not fit in the current privacy bag and would get a different one. In an interview on 5/30/24 at 12:53 p.m., the DON stated he expected staff to be attentive during dining and that when he was a CNA he sat with his residents to promote a home-like environment. The DON stated he encouraged staff to sit with residents while feeding. The DON stated the greatest concern if wound VAC tubing is exposed is dignity and the least amount of tubing possible should be visible. Record review of the facility's policy titled Abuse/Reportable Events with an effective date of 12-1-2018, stated This facility establishes an environment that is as homelike as possible and includes a culture and environment that treats each resident with respect and dignity. It also states, Treating a nursing home resident in any manner that does not uphold a resident's sense of self-worth and individuality dehumanizes the resident.

Based on interview and record review, the facility failed to ensure that residents obtain needed dental services, including routine dental services and to ensure the resident was provides the assistance needed or requested to obtain these service for one of two residents (Residents #1) reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #1. Resident #1 was assessed on 11/07/2022 and observed to have dental issues however did not recieve routine treatment which caused Resident #1 to have a tooth abscess with pain. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings include: Record review of Resident #1's electronic face sheet face printed 03/19/2024 revealed a [AGE] year-old- male admitted to the facility 09/30/2022 and re admitted on [DATE] with diagnoses that included chronic congestive heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), and kidney failure (one or both kidneys no longer work) Review of the quarterly MDS assessment dated [DATE] revealed section L oral/ dental status was not completed. Review of Resident #1's care plan with a problem start date of 11/07/2022 revealed Resident #1 had oral/ dental health problems regarding poor oral hygiene, missing broken teeth, Carious dentition (prevalent chronic infectious disease resulting from tooth-adherent cariogenic bacteria that metabolize sugars to produce acid, which over time demineralizes tooth structure) Review of Resident #1's progress nurse authored by DON 02/23/2024 revealed Resident #1 was seen by the Nurse Practitioner due to his left lower jaw being swollen. Resident #1 was prescribed Augmentin 500 milligram tablets every 12 hours for 7 days due to tooth abscess. Review of the dental referral book revealed no referral for Resident #1 to see the dentist had been completed. Interview on 03/19/2024 at 12:00 PM with Resident #1 revealed he had been in the facility for 3 years. Resident #1 stated he had not been to the dentist since being in the facility and needed to go. Resident #1 stated he had an abscess and was experiencing pain in his mouth but did not describe the pain. Resident #1 stated he was able to eat. Observation of Resident #1 having several missing teeth. Interview on 03/19/2024 at 1:30 PM with the Social Worker revealed she had worked in the facility since February 2024. She stated she was responsible for making the referrals for dental services. She stated typically residents would let her know if a referral was needed. The Social Worker stated she had not made a referral for Resident #1 and was not aware that he needed to be seen by a dentist. The Social Worker stated if the resident had an abscess, then they should have been seen by a dentist. Interview on 03/19/2024 at 3:30PM with the Director of nursing and Administrator revealed if a resident clinically needed to see a specialist, then the resident or any staff could let the Social Worker know and the Social Worker would make the referral. The Director and Administrator stated regarding Resident #1 he was seen by the nurse practitioner for the abscess and was treated for the infection and they were not aware of the resident needed to see the dentist. The Director of Nursing and Administrator stated they both spoke with Resident #1 frequently and he had not voiced any concerns of oral pain. A policy regarding referrals and dental services was requested after exit however the Administrator stated the facility did not have those polices.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of six residents reviewed for medications. The facility failed to administer Resident #1 his 80 milligrams of [MEDICATION NAME] (treats fluid retention caused by [MEDICAL CONDITION]) as ordered for three days. Resident #1 was hospitalized in acute [MEDICAL CONDITION] on 09/04/16. An IJ was identified on 09/12/16. While the IJ was removed on 09/13/16, the facility remained out of compliance at a a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring implementation of the Plan of Removal. These failures could affect any of the facility's 44 residents on the 2nd floor where Resident #1 resided, by placing them at risk for omissions of significant medications ordered prior to the print date of the following month's MARs; and result in deterioration of their clinical state and/or hospitalization . Findings included: 1. Review of the hospital history and physical dated 08/21/16, revealed: Resident #1 was admitted to the hospital for [MEDICAL CONDITION] (an infection which has progressed and caused impaired blood flow to body organs) secondary to a urinary tract infection. He was treated with intravenous (through the vein) antibiotics however, his kidney function began to deteriorate and his 80 mg of [MEDICATION NAME] was discontinued. His [MEDICAL CONDITION] (a condition when the heart's pumping power is weakened causing fluid to back up and leak into the lungs and/or tissues) was stable throughout his hospital stay. A B-Type Natriuretic Peptide (BNP) was drawn on 08/21/16 and was 294 picograms per milliliter of blood (pg/ml) with a normal range of 0 to 100 pg/ml. (BNP is a blood test that increases in numerical value when heart failure worsens and is always higher than that of a normal heart in a person with [MEDICAL CONDITION]). The physical reflected the absence of [MEDICAL CONDITION] (swelling caused by excess fluid trapped in tissue), rales, rhonchi, wheezing or diminished breath sounds (abnormal lung sounds). According to a facility's Face Sheet dated 08/25/16, Resident #1 was admitted on [DATE]. 2. A history and physical dictated by Resident #1's attending physician, MD C, and dated 08/29/16; reflected Resident #1 was admitted to the facility on [DATE] for continued intravenous antibiotics, fluids, and rehabilitation. MD C documented, Pt (Patient) seen sitting in chair in his room. He appeared SOB (short of breath), and told me that this was because he did not have his O2 (oxygen) on, and he just came from the restroom. He normally uses PRN (as needed) and qhs (every night) oxygen per him .Upon exam, I noted that pt has BLE (bilateral lower extremity, meaning both legs) [MEDICAL CONDITION], so I told him to elevate his legs while he is in bed. MD C documented that Resident #1's [MEDICATION NAME] was held due to acute renal (kidney) function and that he had no rales, rhonchi or wheezing, but had slightly labored breathing. 3. A history and physical dictated by Nurse Practitioner (NP) D and dated 08/30/16, reflected, .Pt c/o (complains of) SOB and leg swelling. I told him that his weight went up 3 pounds so he probably has some extra fluid. The daughter reports he weighed 212 when he left the hospital. He reports that the SOB comes on when he is lying down. I told the pt that his blood pressure is low, so I lowered his [MEDICATION NAME] (treats high blood pressure) dose and added a diuretic to help move the fluid NP D also documented Resident #1 ' s weights while in the facility: 08/26/16- 219.2 pounds; 08/27/16-219.8 pounds; 08/29/30- 222.0 pounds. 4. Review of the physician orders [REDACTED]. [MEDICATION NAME] 80 mg QAM (every morning). 5. A history and physical dictated by NP D and dated 08/31/16, reflected, Pt is met walking down the hall with therapist and takes a seat in the living area to talk to me. He has DOE (dyspnea (difficulty breathing) on exertion). Therapist is present. He continues to complain of SOB. He reports that it is worse than yesterday. He reports he had a dry cough that awakened him several times last night. Pt slept with his oxygen on. The therapist reports that the pt does not wear oxygen during exercise and his O2 sat (saturation) stays above 95 %. The pt reports he lost 2 pounds since yesterday when he was weighed this morning. He tells me he feels the [MEDICATION NAME] is working because he urinated frequently and filled 2 urinals during the night. Leg [MEDICAL CONDITION] decreased some. I told the pt we will see what the CXR (chest x-ray) shows that was taken this morning. I told the pt I would order something for his cough at night. I told him this may not work because his cough is due to fluid congestion, but we would try. NP D also documented Resident #1 had no rales, rhonchi, and wheezing, his lungs were clear, but he had labored breathing with walking, but it settled at rest. NP D documented the presence of 2 + [MEDICAL CONDITION] (when a finger is pressed to the area of [MEDICAL CONDITION], and indentation results which rebounds in a few seconds) bilaterally. 6. A history and physical dictated by NP D ad dated 09/02/16, reflected, .He reports less SOB and awakened once last night. Son reports that he has noticed improvement each day for past 2 days. Recent CXR was clear. Weight has not decreased much, but pt reports frequent voiding. Pt. reports that swelling is less. NP D documented Resident #1 clinically improved and less [MEDICAL CONDITION], though weight not much changed 7. The following are Resident #1's nurses' notes from 09/02/16 through 09/04/16: 09/02/16 at 3 PM by RN E: .VS (vital signs) stable. C/O SOB O2 sats 98% with diminished BS (breath sounds) bilat (bilaterally). PRN(as needed) mednebs (medication given through nebulizer) given. 09/03/16 at 5:26 PM by RN F: Resident is alert. Able to voice needs. Making jokes with this writer. Resp (respirations) even and unlabored. No SOB noted at this time. Neb Tx (treatment) given as per resident ' s request. LS (lung sounds) clear to upper lobes. Diminished to bases 09/04/16 at 10 AM by LVN G: Resident sitting at bed side with audible wheezing and shortness of breath with activity resp even labored at times O2 at 2 LPM (liters per minute) via nasal canula in place O2 sat 88 to 91% occ (occasional) cough 2+ [MEDICAL CONDITION] to BLE noted [MEDICATION NAME] (medication given in nebulizer treatment to open airways) given tolerated well O2 sat 97% post neb treatment with O2 at 2LPM family in room with multiple concerns about respiratory status. Call place to ____(name of NP) for ____(Resident #1 ' s attending physician) [MEDICATION NAME] given as order .instructed to remain in bed due to shortness of breath with activity .no wheezing noted post neb treatment. 09/04/16 at 7 PM by LVN G: Resident transferred to ____ (name of hospital) via ambulance on stretcher per family request due to concerns of residents renal and cardiac functions due to use of [MEDICATION NAME]. Resident resp even unlabored breath sound diminished occ non-productive cough O2 sat 96-98% with O2 at 2LPM via nasal cannula. Able to transfer without dyspnea. Resident denies pain or shortness of breath. Resident states he feels better 8. LVN G was interviewed on 09/11/16 at 10:33 AM and stated she was the charge nurse for Resident #1 on 08/28/16 and 09/04/16, two Sunday ' s apart. LVN G stated there was a definite difference in Resident #1 within the one week. LVN G stated on 08/28/16, Resident # 1 had no [MEDICAL CONDITION], was walking and had did not use oxygen. On 09/04/16, she received report from the 11 PM to 7 AM nurse, LVN J, that she administered a breathing treatment for [REDACTED]. LVN G stated Resident #1 was sleeping at 7 AM on 09/04/16 but later she noticed he was short of breath even sitting on the bed side eating breakfast. LVN G stated she administered a breathing treatment around 10 AM. LVN G said Resident #1 had 2+ [MEDICAL CONDITION] from his knees to his feet and his son stated his father was more short of breath. LVN G stated since she only worked weekends, she looked at Resident #1 ' s clinical record and noticed the order written 08/30/16 for Resident #1 to receive 80 milligrams of [MEDICATION NAME] every morning. LVN G stated she looked at Resident #1 ' s September 2016 MAR and noticed the [MEDICATION NAME] had not been given; wrote in the order on the MAR and administered the [MEDICATION NAME] to Resident #1. LVN G stated Resident #1 was better after his nebulizer treatment but he voided two urinals full of urine before he left to the emergency department (ED) around 5:30 PM on 09/04/16. On 09/12/16 at 10:10 AM, The Central supply Director was asked to find out the volume capacity of the facility urinals. On 09/12/16 at 10:20 AM, the Central supply director stated a urinal had a volume capacity of 1000 milliliters (one liter). 9. Review of Resident #1's August 2016 MARs and Med-Select automated dispensing machine reports revealed the 80 milligrams of [MEDICATION NAME] order was administered to Resident #1 on 08/30/16 and 08/31/16. Review of Resident #1's [MEDICATION NAME] blister pack dated 08/31/16, revealed seven [MEDICATION NAME] tablets were dispensed by the pharmacy. The Med-Select automated dispensing report for Resident #1 on 08/30/16, revealed four 20 milligram tablets of [MEDICATION NAME] were dispensed. Interview with MA I, the medication aide who documented giving Resident #1 his [MEDICATION NAME] on 08/31/16, revealed the [MEDICATION NAME] had been delivered from the pharmacy in time for the 8 AM dose on 08/31/16. MA I stated she administered the first dose from the blister pack on that day but did not administer Resident #1 [MEDICATION NAME] during September 2016, because it was not on his September 2016 MARs. Observation of Resident #1's [MEDICATION NAME] blister pack on 09/09/16 at 1:31 PM with the DON present, revealed five [MEDICATION NAME] tablets remained of the seven dispensed by the pharmacy on 08/31/16. 10. The hospital ED records dated 09/04/16 revealed Resident #1 arrived at the ED at 6:16 PM with a chief complaint of shortness of breath. The ED nurses notes reflected 40 milligrams of [MEDICATION NAME] was administered at 8:03 PM and Resident #1 had a urine output of 900 milliliters after the dose. A BNP drawn at 9:21 PM revealed a result of 1058 pg/ml (A BNP level above 900 is indicative of severe [MEDICAL CONDITION]). The ED physician documented a [DIAGNOSES REDACTED]. The ED physician documented the presence of 2+[MEDICAL CONDITION] in the legs and rales (bubbling or rattling sound in the lungs) with [MEDICAL CONDITION] (low blood oxygen) on room air and that Resident #1 does not usually require oxygen. The ED physician documented Resident #1 was [MEDICATION NAME] (increased his urine output) but his symptoms did not improve. The ED physician ' s recommendation was for Resident #1 to be hospitalized . 11. Review of the hospital records obtained on 09/12/16, revealed on 09/04/16 at 10:47 PM, Resident #1 was admitted to the hospital telemetry unit (a unit where special machines are used to help staff closely monitor residents, especially for changed in blood pressure and the rate and rhythm of the heart). The 09/05/16 hospital history and physical [DIAGNOSES REDACTED]. 12. On 09/09/16 at 11:49 AM, NP D was interviewed and stated she ordered the [MEDICATION NAME] for Resident #1 on 08/30/16 around 2 PM, after examining him. She stated Resident #1 was, Clearly volume overloaded and it certainly did not help missing the [MEDICATION NAME]. He had [MEDICAL CONDITION] and increased problems breathing and that is why I ordered the [MEDICATION NAME]. NP D stated this could have been prevented by three letters: EHR (electronic health record). 13. MD C, Resident #1's attending physician was interviewed on 09/12/16 at 1:47 PM. He stated when he arrived at the facility on 09/05/16 he wondered why Resident #1 had been hosptalized on [DATE]. He stated he reviewed the clinical record and discovered Resident #1 had missed three doses of [MEDICATION NAME], on 09/01/16 through and including 09/03/16. MD C stated if Resident had received the [MEDICATION NAME] as ordered he probably would not have ended up in the hospital. MD C stated, I think it was avoidable and I told the DON that. 14. On 09/09/16 at 9:41 AM, the DON was interviewed and stated on 09/05/16, MD C discovered Resident #1 missed three doses of [MEDICATION NAME] during a review of hospitalization s over the weekend. The DON stated she determined the [MEDICATION NAME] had been missed and started an investigation which was still on-going. The DON stated there were three failures identified so far which included, the Medical Records Director printed the September 2016 MARs late; RN A did not transcribe Resident #1 ' s [MEDICATION NAME] order to the September 2016 MAR; and LVN B failed to identify the [MEDICATION NAME] order had not been transcribed to Resident #1 ' s September 2016 MAR during his 24-hour chart audit on 08/31/16. The DON stated the 24-hour chart audits were conducted by the 11 PM to 7 AM shift every night. The DON stated the facility had started to in-service staff on 09/05/16. The DON stated the September 2016 MARS were printed on 08/31/16 around 5 PM and facility policy was to print the next month MARS two days prior to end of the month. The DON stated RN A could have used a blank MAR available at the nursing station to capture the [MEDICATION NAME] order for Resident #1. The DON provided an in-service dated 09/05/16, titled 24 hour chart check of physician orders. The signature page revealed only nine nurses had been in-serviced. Of the nine, only three staff worked second floor where the error occurred and none of these three conducted 24- hour chart audits because they did not work the 11 PM to 7 AM shift. Neither RN A nor LVN B attended the in-service. 15. On 09/12/16 at 10:36 AM, the Medical Records Director was interviewed and stated she had been employed with the facility since September 2014. The Director stated the facility policy was to print the MARs for the next month two days prior to the beginning of the new month. The Director stated the September 2016 MARs were printed late. She stated she printed them on 08/31/16 just before she left, around 6 PM. The Director stated she was involved with a Medicare audit and that was the reason for the late print. The Medical Records Director stated she was not sure about the date or conversation, but thought she had informed the DON of the MARs being printed late. She added that on 09/05/16 or 09/06/16, she had a meeting with the DON to formalize the end of month printing of the MARs and that the process had not changed but the dates were more concrete depending how many days were in the month. The Medical Records stated she could not remember any other time that the MARs had been printed late. 16. A was interviewed on 09/10/16 at 1:05 AM. RN A stated she recalled RN E telling her during the change of shift report on 08/30/16 at 11PM, that Resident #1 received a STAT (give now) dose of [MEDICATION NAME]. RN A stated later in her shift during the 24 hour chart audit, at 2 AM on 08/31/16, she noted the [MEDICATION NAME] order and transcribed the order onto Resident #1 ' s August 2016 MAR for the 08/31/16 8 AM dose. She stated she did not transcribe the orders to the September2016 MAR because they had not been printed out yet. RN A was interviewed again on 09/13/16 at 12:33 PM and asked why she did not use a blank MAR and write in the [MEDICATION NAME] order and Resident #1 ' s identifying information. RN A stated it did not occur to her to do that because the MARs had never before been printed late. 17. On 09/12/16 at 2:20 PM, the Administrator and DON were informed that an IJ was identified. They were asked to provide a Plan of Removal and on 09/13/16 at 11:40 AM, the Plan of Removal was accepted and included: Plan of Removal Regarding Resident #1 Resident #1 had a new order for [MEDICATION NAME] 80 mg (milligrams) po daily for [MEDICAL CONDITIONS] on 08/30/2016. The facility staff, RN E (day shift) and MA I (day shift) was able to administer the initial medication on 08/30/16 and 08/31/16. The facility staff, MA I and RN F (weekend day/evening shift) failed to administer the succeeding medications from 09/01/16 to 09/03/16 due to the following events: (1). Medication order was not transcribed to the MAR for the month of September 2016 by RN A (night shift). (2). Significant medication error noted by MD C. It was determined that Resident #1 missed 3 doses of [MEDICATION NAME] 80 mg po from 09/01/16 - 09/03/16. (3). Medical Records Director, LVN and Unit Clerk did not print new month MARS timely due to working on items for a ZPIC audit and processing a high volume of telephone orders. (4). 24 hour chart check procedure was not followed by LVN B, (PRN) LVN J, and LVN Q. Resident #1 had a complaint of SOB on 09/04/16 and was given the ordered [MEDICATION NAME], and was then transferred to the acute hospital. On 09/05/16, the attending physician, MD C , noted the missed doses of [MEDICATION NAME] 80 milligrams po daily from 09/01/16 to 09/03/16 (3 days) during facility visit and chart review. At that time, the DON was made aware of the findings by MD C. After the DON's investigation, the investigation findings were self-reported to DADS (Department of Aging and Disability Services) on 09/06/2016. Facility leaders and staff, the Administrator, DON, ADON L, ADON M, Medical Records Coordinator, and Unit Clerk, initiated the following protocol to address items 1-4 listed above: All new orders from 08/30/16 to 09/01/16 were verified by the facility staff to check that all medications were transcribed accordingly for the following month (September 2016). On 09/05/16, after the facility staff investigation, the DON, ADON, and Medical Records Director coordinator initiated the in-services to 9 licensed nurses ( 2nd floor: two on day shift, one on evening shift; 3rd floor: two on day shift, one on evening shift, two on night shift on, the Medical Records Director/LVN, and the Unit Clerk on the following: - Completion of Recapitulation order on a monthly basis and transcription to MAR - Carrying out of new order and writing of the new medication order to the current month MAR and the following month MAR. - 24-hour Check Process of telephone orders Please note in-servicing is ongoing. To prevent recurrence: (1) The facility has initiated the attached Internal Facility Protocol (2) The DON/Designee will report to QAA (Quality Assessment and Assurrance) team on a monthly basis any deficient practice regarding item 2 for a period of six months. The AQQ team will review quarterly thereafter. (3) All licensed nurses and medication aides will be re-in-serviced on Medication Administration by the DON/Designee with the following focus agenda: -Matching of the available medications in cart and the actual MAR -Any discrepancies on the available medication in the cart and MAR will be addressed accordingly by the licensed nurses. (4) Medical Records Director or Designee will print all orders for the new month seven days prior to the last day of the month and MARS/TARS (treatment administration record) for the following month by the 28th of the preceding month if there are 30 days in the month; or by the 29th of the preceding month if there are 31 days in the month. These items will be placed in a binder designated for new month MD Orders/ MARS/ TARS. ADON or Designee will be assigned for checking monthly recapitulation by the last day of the month. -Licensed nurse who notes telephone orders obtained between the print dates of the new month MAR/TAR to the 1st day of the new month, will place a copy of those telephone orders in the new MAR/TAR binder. This will assist the licensed nurse with following through on transcription of the order onto the new month MAR/TAR. -The licensed nurse who notes the telephone orders must also make the appropriate corrections to the printed physician orders [REDACTED]. (5) At this time, all licensed nurses and medication aides on the evening shift were in-serviced by the DON/ RN K, ADON/MRD (Medical Records Director)/Designee. The in-coming licensed nurses and medication aides for the succeeding shifts will be in-serviced by DON, RN K, ADON, LVN N, ADON, Medical Directors Director, or Designee prior to starting the shift. All in-services for remaining licensed nurses and medication aides (day shift, evening shift, night shift, PRN, weekend double, and weekend supervisors) will be completed by the end of the day on 09/14/2016. Any new employees or employees on leave, licensed nurses or medication aides will receive the above mentioned in-service prior to beginning floor orientation. INTERNAL FACILITY PROTOCOL Subject: 24 Hour Chart Review Protocol PURPOSE: The Transcription Review is meant to serve as checks and balances system to ensure the early detection of errors and omission of orders. This safeguard measure is accomplished by conducting a review of all charts as a part of charge nurse shift duties. Process: (1) ALL CHARTS on the unit shall be checked each night by the Night Shift charge nurses for newly written physician orders. (2) DON/ADON is responsible for ensuring the entire night audit procedure is completed nightly and corrections are made daily. (3) The staff member who discovers a medication error will notify the DON/ADON and initiate a Medication Error and/or Incident Report. The ADON is responsible for ensuring that the appropriate action and notification is taken as clinically indicated. (4) Night shift charge nurses shall utilize the 24 Hour Shift Audit form and continuation page when conducting audit review of charts. (5) The ADON and Medical Records Director will review the 24 Hour Check daily and follow-up as needed. (6) The following documents shall be reviewed for errors in transcription, omission of initials, and/or lack of pertinent documentation: Physician orders, medication and treatment record, diagnostic requisitions for lab specimens, consultant and radiology. (7) Night shift charge nurses shall review all charts on the unit for new and renewed orders from the previous day. All errors of transcription shall be immediately brought to the attention of the DON/ ADON for follow-up action as needed. The physician or designee shall be notified of any medication errors. (8) For medications errors a special incident report shall immediately be initiated by the staff person who finds the error. Notify the physician or designee and follow the physician's order [REDACTED]. (9) When an improperly transcribed order results in a medication error, initiate the following: The charge nurse who finds the error shall take the appropriate steps to remedy the error. (10) Medical Records Director or designee will print all orders for the new month seven days prior to the last day of the month and MARS/TARS for the following month by the 28th of the preceding month if there are 30 days in the month, or by the 29th of the preceding month if there are 31 days in the month. These iterms will be placed in a binder designated for new month MD orders/ MARS/ TARS. ADON or designee will be assigned for checking monthly recapitulation by the last day of the month. All variances shall be brought to the attention of the physician for correction as needed. --Licensed nurse who notes telephone orders obtained between the print dates of the new month MAR/TAR to the 1st day of the new month, will place a copy of those telephone orders in the new month MAR/TAR binder. This will assist the licensed nurse with following through on transcription of the order onto the new month MAR/TAR. --The licensed nurse, who notes the telephone orders must also make the appropriate correction to the printed physician orders. 18. After the facility's Plan of Removal was accepted on 09/13/16, on-site monitoring was started. The interviews were conducted on 09/13/16. The interviews conducted during the on-site monitoring included staff from all shifts including weekend and prn staff. There was a total of 12 staff interviewed: There were two nurses interviewed who worked the 11 PM to 7 AM shift (LVN J and RN A) There was two nurses interviewed who worked weekend double shifts from 7 AM to 11 PM (RN F and LVN O) There were three nurses interviewed who worked the 7 AM to 3 PM shift and the 3 PM to 11 PM shift (LVN J, LVN H and RN E) The Medical Records Director was interviewed. ADON, LVN N, was interviewd. ADON, RN K was interviewed The DON was interviewed. RN M, the MDS coordinator, was interviewed All staff who were interviewed confirmed that they had received the in-service training. They were all knowledgeable in what to do regarding the 24 hour chart check and transcription to the MAR. The Medical Records Director was knowledgeable about when to print the upcoming month's MARs. In addition, five residents (Residents # 2, #3, #4, #5, and #6)with admissions or new orders on 08/30/16 or 08/31/16, were reviewed to ensure proper transcription of orders to the MAR. On 09/13/16 at 2: 55 PM, The Administrator was notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy. and a scope of pattern because the facility was still monitoring implementation of the Plan of Removal. An interview with the Administrator on 09/16/16 at 9:33 AM revealed 44 residents resided on the 2nd floor according to a Resident roster, dated 09/11/16.