Every finding on record at Avir at Tierra Este

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 6 Residents reviewed for Resident Rights. The facility failed to ensure Resident #1's dignity was maintained when she was left in bedding that was wet with urine. This failure put incontinent residents at risk of development of skin irritation, skin breakdown and altered comfort. The findings include: Review of the Face Sheet dated 08/03/26 for Resident #1 revealed original admission date 7/18/2024 and re-admission date 5/27/2026.Review of the Physician Progress Note dated 07/29/26 for Resident #1 revealed [AGE] year-old female with significant history of COPD on oxygen, dependence on supplemental oxygen.Review of the Quarterly MDS dated [DATE] for Resident #1 revealed, BIMS Summary Score 15 (Cognitively intact). Incontinent of bowel and bladder. Active Diagnoses: COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), Heart Failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), Respiratory Failure (the lungs cannot get enough oxygen into the blood or cannot remove enough carbon dioxide from the body). Other Health Conditions: Shortness of breath. Oxygen therapy. Review of the Care Plan revised on 06/21/2025 for Resident #1 revealed that she was incontinent of bowel and bladder. Interventions: Use incontinent pads/briefs as needed.During an interview at 2:40 p.m. with CNA H revealed Resident #1 was alert, oriented to person, place, time and situation. She said the resident was confused at times. She said the resident was incontinent of bowel and bladder and used disposable brief. She said the resident did not like to use the bedpan and preferred to use disposable briefs. She said the resident would call for assistance when she was soiled and needed to be changed.During an observation on 08/03/26 at 5:18 p.m. with the DON and ADON G Resident #1 was lying in bed awake and said that she had called for assistance to ask that the CNA change her sheets because they were wet with urine and the CNA had refused to change her sheets. She said, The Aide came to my room and said, she had just finished changing her and that the sheets are not wet. The CNA just placed a clean cloth under pad over the wet sheets, but look the top sheet is still wet, and she did not change it. The DON checked the resident's brief and was wet with urine. The DON and ADON turned the resident to her right side, and noted the top sheet was wet, and there was a light green cloth under pad that was dry. The resident did not have any skin irritation, or rash on the buttock or perineal area. When the DON lifted the under pad it was observed that the fitted sheet was wet and had dried urine ring on the sheet. The DON said that the CNAs should check the residents for incontinence every two hours and as needed. She said that failure to provide timely incontinent care placed the residents at risk of skin irritation and breakdown.During an interview on 08/03/26 at 5:25 p.m. the DON said that the nurses should check throughout the shift that the CNAs are making rounds every two hours and as needed to provide incontinent care.Review of the facility's policy and procedures on Urinary Incontinence revised in August 2022 revealed, Policy Statement: Management of incontinence will follow relevant clinical guidelines. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. Incontinent care should be individualized in order to maintain comfort and skin integrity.Review of the facility's policy and procedures on Resident Rights revised on February 2021 revealed, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity;

Based on observation, interview and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #1) reviewed for respiratory care. -The facility failed to ensure oxygen was administered to Resident #1 according to physician's orders. Resident had an order to administer oxygen at 3 L/min and was receiving 4 L/min via nasal cannula on 08/03/26 on the evening shift.-Resident #1 was not provided access to a portable oxygen tank when she was offered showers.This deficient practice could place residents who receive oxygen at an increased risk of developing respiratory complications.The findings include: Review of the Face Sheet dated 08/03/26 for Resident #1 revealed original admission date 7/18/2024 and re-admission date 5/27/2026.Review of the Physician Progress Note dated 07/29/26 for Resident #1 revealed [AGE] year-old female with significant history of COPD on oxygen, dependence on supplemental oxygen.Review of EMS Care Report dated 07/28/26 at 8:05 p.m. for Resident #1 revealed [AGE] year-old female with Chief Complaint of Chest Pain. Upon arrival at 8:09 p.m. patient was located supine on bed. Patient was conscious, oriented to person, place, time and situation, Blood Pressure 152/82, Heart Rate 98, SpO2 98, and Respirations 18, Respiratory Effort was normal. Patient stated after taking a shower she felt chest pain. Patient stated medical history of COPD. Patient presented with sinus tachycardia (a faster-than-normal heartbeat over 100 beats per minute) on the monitor. Patient was administered 324 mg of aspirin as well as 4 L/min of oxygen via nasal cannula. Patient condition improved after administration of aspirin and oxygen. The patient was transferred to hospital Emergency Room.Review of Hospital emergency room Paperwork dated 07/29/26 for Resident #1 revealed, admit date [DATE] at 8:48 p.m. patient brought in by ambulance from nursing home to the emergency room with complaints of chest pain after her shower. Past Medical History of COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra-mucus, and air flow obstruction). Chief Complaint: Chest Pain. Vital signs Respiratory Rate 18 SpO2/Pulse Oximetry 96%. Alert, no acute distress and is in stable condition. Pulse Ox interpretation: Normal on room air. Respirations non-labored. Oriented to person, place, time and situation. Plan: Labs for UTI, Troponin I, chest x-ray and EKG. discharged [DATE] at 12:16 a.m. Impression/Plan: Acute UTI, Chest wall pain. New Order: Cephalexin 500 mg oral capsule 1 capsule twice daily for 10 days for UTI. Rationale: Reassessment at the time of disposition demonstrates that the patient is in no acute distress. Patient has remained hemodynamically stable throughout the entire ED visit and is without objective evidence for acute process requiring urgent intervention or hospitalization. No necessity for further emergent imaging or laboratory analysis. The patient is stable for discharge, Reexamination/ Reevaluation: UA: UTI; all other labs are negative/unremarkable. Vital Signs: Heart Rate 85, Respirations 18, Blood Pressure 126/71, SpO2/Pulse Oximetry 96%. Impression/Plan: Acute UTI and Chest Pain. Disposition: 07/29/26 at 12:16 a.m. Review of the Quarterly MDS dated [DATE] for Resident #1 revealed, BIMS Summary Score 15 (Cognitively intact). Incontinent of bowel and bladder. Active Diagnoses: COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), Heart Failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), Respiratory Failure (the lungs cannot get enough oxygen into the blood or cannot remove enough carbon dioxide from the body). Other Health Conditions: Shortness of breath. Oxygen therapy.Review of the Care Plan revised on 06/21/2025 for Resident #1 revealed, Resident is a risk for Respiratory infection/distress, hypoxia (a medical condition where the body's tissues and organs do not get enough oxygen to work properly), and SOB related to COPD. Interventions: Administer oxygen as ordered. Administer Nebulizer treatment as ordered.Review of the Physician Order Summary dated 08/03/26 for Resident #1 revealed Diagnoses: COPD, dependence on supplemental oxygen. Oxygen at 3 L/min via nasal cannula every shift for SOB and to maintain pulse ox > 90 %. Review of the Medication Administration Record dated August 2026 for Resident #1 revealed Start Date: 07/29/26 Cephalexin Oral Capsule 500 mg one capsule by mouth two times a day for UTI for 10 daysReview of the Nurse Treatment Record dated August 2026 for Resident #1 revealed Oxygen at 3 L/min via nasal cannula every shift for SOB and to maintain pulse ox > 90 %. During an observation and interview on 08/03/26 at 8:51 a.m. Resident #1 was awake lying in bed, alert, oriented to person, place, time, and situation. The resident said she has been at the facility for two years. The Resident said that last week on Tuesday during the evening shift one of the CNAs had wheeled her to the shower room to give her a shower and had not placed her oxygen prior to taking her to the room. She said she had told the CNAs that she could not be without her oxygen, and the CNA had said that it was Ok because it would not take long to give her a shower. She said that the CNA had checked the portable oxygen tanks that were in her room and had said that the tanks were empty. She said, While I was being showered, I started to become very anxious and told her that I needed to be placed on the oxygen. She said that it took a long time before she was taken back to her bed after the shower was completed because she needed a Hoyer Lift to be transferred from the shower chair to her wheelchair. She said, By that time, I was desperate because I was having problems breathing. It was observed that the resident was on 3 L/min of oxygen via nasal cannula.During an interview on 08/03/26 at 3:03 p.m. LVN A said he was assigned to Resident #1 on the 2-10 shift. He said that the resident was on continuous oxygen via nasal cannula at 3 L/min. He said that he did not know if the CNAs connected the resident to the portable oxygen tanks on 07/28/26 when they showered the resident on that day. He said Resident #1 was complaining of chest pain after she was showered and put back in bed by the CNAs and he had called the Nurse Practitioner B and got an order to send the resident to the emergency room via EMS. He said he had notified the DON of resident's change in condition. He said Resident #1 had returned back from the hospital after he had left at the end of his shift on that day. He said the resident returned with a new order for Cephalexin Oral Capsule 500 mg one capsule by mouth two times a day for UTI for 10 days. He said, I remember that when I went to the resident's room to assess the resident on that day, the resident had her oxygen cannula in place and was connected to the oxygen concentrator. I checked the resident's oxygen saturation and was at 97%. I also checked that the oxygen liters and was set at 3 L/min and that is when I noted that the oxygen tubing was not completely inserted to male connector on the oxygen concentrator. So, whoever reconnected the oxygen after the shower on that day, did not reconnect the oxygen tubing properly on the oxygen concentrator. He said the nurse needed to disconnect the oxygen from the concentrator when they needed to shower the resident and the CNAs were not allowed to reconnect the resident to the oxygen concentrator to ensure that the resident was receiving the prescribed liters of oxygen.During an interview on 08/03/26 at 3:12 p.m. DON revealed that when a resident was on continuous oxygen the nurses were responsible for switching the oxygen from the concentrator to the portable oxygen tanks when the resident was going to be showered. She said that if a resident had a physician's order for continuous oxygen, the CNAs should never shower a resident without using the portable oxygen tanks. She said that the risk of not administering the prescribed oxygen as ordered could place the resident in respiratory distress. She said that she was not aware of any concerns related to the CNAs disconnecting a resident from the oxygen concentrator and showering a resident without placing the resident on the portable oxygen tank. She said the Nurses and CNAs had been trained that only the nurses disconnected the oxygen and the nurses were responsible for setting the liters of oxygen according to physician's orders.During an interview on 08/03/26 at 3:22 p.m. CNA C on the 2-10 shift revealed she had been assigned to Resident #1 on 07/28/26 and CNA D had assisted her to transfer the resident from the bed to the shower chair. She said that she could not remember if the resident was placed on the portable oxygen tank on that day when she had showered the resident. She said that they rotate assignments daily and are assigned to work in different halls each day. She said that after they had completed the shower, they put the resident back in bed and she was complaining about chest pain and shortness of breath. She said that they had notified LVN A and he had immediately gone to the room to assess the resident. She said that the resident was sent to the hospital by ambulance on that day. She said that the nurse had placed the resident on the oxygen via the oxygen concentrator. She said the CNAs had been trained that only the nurses could disconnect the oxygen and only the nurses could reconnect the oxygen.During an interview on 08/03/26 at 3:53 p.m. LVN E on the 2-10 shift said that residents who were on continuous oxygen are showered without the oxygen because the oxygen concentrator cannot be in the shower due to safety issues. He said, it would not be safe because the concentrator would need to be connected to the electrical outlet. He said that failure to administer the oxygen according to physician's orders could place the resident in respiratory distress. He said that he did not pay attention to when the CNAs were showering residents because he was busy doing his work and did not know if the resident was placed on the portable oxygen tanks when they showered the residents. He said that the CNAs had been trained that only the nurses disconnected the oxygen and only the nurses set the number of liters according to physician's orders.During an interview on 08/03/26 at 4:29 p.m. the Administrator revealed that she was not aware of any resident concerns related to not getting their oxygen according to physician's orders or of showering residents who were on continuous oxygen without the oxygen. She said that each room had a shower and the CNAs used portable oxygen tanks when the residents needed to be showered, if the resident had physician's orders for continuous oxygen. She said that failure to administer oxygen as ordered by the attending physician could place the resident at risk of respiratory distress.During a telephone interview on 08/03/26 at 4:35 p.m. CNA D said that she remembered Resident #1 was scheduled to be showered on 07/28/26 during the 2-10 shift. She said that she did not remember assisting CNA C on that day to transfer the resident from the bed to the shower chair using the Hoyer Lift. She said she was on break, and upon returning to the unit she had noted that the door to Resident #1's room was closed. She said that she had noted that CNA C had already showered the resident and the resident was already in bed and had her oxygen. She said that she was aware that Resident #1 was on continuous oxygen. She said that she remembered that EMS had come to take the resident to the hospital. She said the CNAs had been trained to ask the nurse to place those residents that had orders for continuous oxygen on the portable metal oxygen tanks for them to take the resident to the shower room for their shower. She said that only the nurses could reconnect the oxygen and set the oxygen liters.During a second interview on 08/03/26 at 3:41 p.m. CNA C revealed she had disconnected the resident from the oxygen concentrator on 07/28/26 to give the resident a shower and had placed her on a portable oxygen tank. She said that after she had showered the resident and placed her back in bed, she had turned on the oxygen concentrator and had connected the resident's oxygen tubing to the oxygen concentrator on that day. She said the CNAs had been trained that only the nurses could disconnect and reconnect the oxygen.During an interview at 4:29 p.m. Administrator revealed that she was not aware of any resident concerns related to not getting their oxygen according to physician's orders or of showering residents who were on continuous oxygen without the oxygen. She said that each room had a shower and the CNAs used portable oxygen tanks when the residents needed to be showered, if the resident had physician's orders for continuous oxygen. She said that failure to administer oxygen as ordered by the attending physician could place the resident at risk of respiratory distress. During an observation on 08/03/26 at 4:44 p.m. Resident #1 was lying in bed awake, it was observed that the resident was on 4 L/min of oxygen via nasal cannula. It was observed that the water humidifier bottle was empty. It was observed that there were two portable oxygen metal cylinders in the resident's room. One tank had an oxygen regulator attached to the oxygen tank and the other portable oxygen tank did not have an oxygen regulator.During an interview on 08/03/26 at 4:47 p.m. LVN A said Resident #1 should be on 3 L/min of continuous oxygen via nasal cannula.During an observation and interview on 08/03/26 at 4:48 p.m. with LVN A and the DON Resident #1 was receiving 4 L/min of oxygen via nasal cannula. LVN A said, I don't know who set it at 4 L/min. He said he had not noted that the humidifier bottle was empty.During an interview on 08/03/26 at 4:51 p.m. CNA F revealed that today she was assigned to Resident #1 on the 2-10 shift. She said that only the nurses can disconnect the oxygen. She said that only the nurses could reconnect the oxygen and set the liters of oxygen.During an interview on 08/03/26 at 4:53 p.m. Resident #1 revealed that on 07/28/26 the CNA had taken her to shower room to give her a shower without her oxygen. She said, I told the CNA that I could not be without my oxygen, and she told me not to worry that she would shower me real fast and put me back on my oxygen. The CNA told me that the two portable oxygen cylinders in the room were empty and that was why she was going to shower me without my oxygen. I started to have pain in the middle of the chest, and she put me back in bed after the shower and connected me to the oxygen and I started to feel better. The resident said that the aides do whatever they want to do and do not listen to them. She said that the CNAs disconnect and reconnect her oxygen when they give her a shower.During an observation and interview on 08/03/26 at 5:07 p.m. with the DON and LVN A there were two portable oxygen cylinders in the resident's room that were empty. The DON said the empty tanks should be removed and stored in the oxygen room.Review of the facility's policy and procedures on Oxygen Administration revised October 2019 revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify there is a physician order. For this procedure. Review the physicians orders. Facility protocol for oxygen administration. Steps in procedure: Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Place appropriate Oxygen device on the resident i.e. nasal cannula. Check mask/oxygen cannula, tank, humidifying bottle, etc., to be sure they are in good working orders and are securely fastened. Be sure they're in good working order and are securely fastened. Be sure there is water in the humidifying bottle and that the water level is high enough that the water bubbles as oxygen flows through. Periodically recheck water level and humidifying bottle.

Based interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #1) six residents reviewed for catheter care.- The facility failed to ensure LVN A appropriately monitored and assessed Resident #1 following catheter removal, responded timely to repeated reports of urinary retention, and ensured proper catheter reinsertion resulting in prolonged urinary obstruction, traumatic catheterization, septic shock, hemodynamic instability, and ICU hospitalization.- The facility failed to ensure LVN K removed Resident #1's catheter on 03/20/26 during the day shift when Bladder Training was completed according to physician's orders.- The facility failed to ensure Licensed staff monitored Resident #1's urinary output for 24 hours when LVN A removed the catheter 03/23/26.The visit was re-opened after Enforcement Review on 05/16/26 at 8:14 a.m.An immediate jeopardy situation was identified on 05/16/26. The Immediate Jeopardy template was provided to the facility on [DATE] at 4:12 p.m. While the Immediate Jeopardy was removed on 05/18/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for minimum harm, due to the facility's need to evaluate the effectiveness of their corrective systems.This failure could place residents at risk of delayed treatment/intervention, decline in health and/or risk of death.Findings included: Closed Record review of the Face Sheet dated 04/27/26 for Resident #1 revealed admission Date was 03/09/26 and was discharged to acute care hospital on [DATE] at 10:03 p.m.Review of Hospital transfer admission paperwork sent to the facility prior to admission on [DATE] revealed a Consult Note dated 02/26/26 for Resident #1 revealed, Chief Complaint: Patient has lingering pain to his right flank/hip area. Pain is exacerbated with movement. Reason for Consultation: Acute urinary retention. Patient presented to emergency room for right flank pain and low blood pressure. Urology was consulted due to acute urinary retention. Computed Tomography abdomen does note distended urinary bladder with mild bilateral ureteral and renal pelvic prominence. Upon examination patient does have indwelling catheter draining yellow-colored urine with trace of blood. Assessment and Plan: Bladder outlet obstruction. Acute urinary retention, Gross hematuria (visible blood in the urine) Plan: Keep indwelling Foley catheter in place. Patient will need to discharge home with indwelling Foley catheter due to large initial urinary output.Review of Hospital Patient Depart Summary dated 03/09/26 at 8:13 p.m. for Resident #1 revealed, follow-up with Urologist within 10-14 days.Review of History & Physical dated 03/10/26 written by attending physician for Resident #1 revealed [AGE] year-old male with past medical history of, anxiety (a feeling of fear, dread, unease, or worry, often accompanied by physical symptoms like a rapid heartbeat or tension) , PTSD (a mental health condition triggered by experiencing or witnessed a terrifying, life threating or traumatic event), and right flank pain. Physical Exam: Genitourinary: Non-distended bladder. Summary of Findings: Anxiety, Abdominal Pain. Plan: Psych consult if worsening symptoms. The History and Physical did not document resident had a history of Obstructive and Reflux Uropathy (is a blockage preventing urine from leaving. It can lead to infection, high blood pressure and permanent scarring if not treated. Reflux Uropathy is urine flowing backward from the bladder to the kidneys) or Acute Kidney FailureThe sudden loss of kidney function typically occurs within hours or days. It causes a rapid buildup of waste products and toxins in the blood and disrupts fluid/electrolyte balance).Review of the Physician Progress Note dated 03/24/26 at 7:39 p.m. written by the physician after Resident #1 had been sent to the hospital via EMS at 5:36 p.m. revealed, Reason for Visit: Follow up and no urine output. History: This is a [AGE] year-old male with a past medical history significant for anxiety, PTSD (a mental condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event). Current Status: Patient with no urine output following foley catheter removal. Noted abdominal distention, though patient denied discomfort or pain. Foley catheter was reinserted due to failure to void. Upon insertion, no urine output was obtained; a blood clot was noted in the catheter upon removal nursing staff were instructed to reinsert the foley and irrigate with normal saline. Following reinsertion and irrigation, there was still no urine output. A STAT bladder ultrasound was ordered, which demonstrated approximately 1500 ml urinary retention and evidence of left-sided hydronephrosis (the swelling of the kidney caused by a backup of urine). Due to persistent obstruction despite catheter reinsertion and irrigation, and significant retention with upper tract involvement, the patient was transferred to the ER for urgent urologic evaluation and definitive Foley placement. Date of Service: 3/24/26.Review of Hospital paperwork dated 3/25/26 for Resident #1 revealed, Chief Complaint: Patient coming from long term care facility for frank bloodn urine from foley exchange yesterday. Per family, patient had a Foley catheter exchange yesterday and now has approximately 100 cc of frank blood in the foley bag. Presented with markedly distended bladder and non-draining Foley. History of Present Illness: prior urinary retention (inability to completely empty the bladder, or in some cases, to pass urine at all)/bladder outlet obstruction (is a partial or complete blockage at the base of the bladder that slows or stops urine from exiting the body), and chronic anticoagulation (taking blood thinner medication on a long-term basis to prevent dangerous blood clots from forming or getting larger) presents from nursing facility with urinary retention, gross hematuria (blood in the urine that is visible to the naked eye), and shock (the body's severe, toxic overreaction to an infection). Resident was recently hospitalized from [DATE] to 03/09/26 for urinary retention/bladder outlet obstruction. He now presents from nursing facility after a traumatic foley catheter that was not draining, with markedly distended bladder and gross hematuria. On arrival he was noted to be tachycardic (an abnormal fast resting heart rate), tachypneic (rapid and shallow breathing), and in increased respiratory distress/work of breathing, which improved after Foley exchange and bladder decompression. Approximately 45 minutes prior to arrival, pt. became increasingly lethargic (having absolutely zero energy, feeling incredibly sluggish, and being unable or unwilling to move or do anything). Diagnoses: Septic Shock due to Acute UTI (a sudden bacterial infection in the urinary system), Acute blood loss anemia (a sudden and dangerous drop in red blood cells caused by rapid bleeding) transfuse supportively as needed. Bladder outlet obstruction, Gross hematuria. Admit to ICU in critical but stable condition with urology consultation.Review of admission MDS dated [DATE] for Resident #1 revealed Entry Date: 03/09/26 admitted from acute care hospital; Clear speech makes self-understood and understand others. BIMS Score 15 (Cognitively intact). Indwelling catheter. Active Diagnoses: Anxiety Disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), Renal Failure (is when the kidneys stop working properly, are unable to filter waste, remove excessive fluid, and balance chemicals in the blood), Obstructive Uropathy. High Risk Medications: Antianxiety, antidepressant, anticoagulant.Review of the Care Plan dated 03/10/26 for Resident #1 revealed Resident had an indwelling catheter r/t obstructive and reflux uropathy. Interventions: Catheter as ordered. Monitor and document intake and output as per facility policy. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor for pain and discomfort due to catheter. Monitor/record/report to MD signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating pattern.Review of Care Plan Conference dated 03/17/26 at 12:00 p.m. for Resident #1 revealed, Attendance at Meeting: RN, SW, Therapy, Resident Representative/Family, and Activities. Meeting Type: New Resident Conference. Diagnoses: Obstructive and Reflux Uropathy, Acute Renal Failure. ADON discussed with spouse about the foley catheter and being seen by Urologist. Family: Agreed. Signed by: Social Worker.Review of Physician Order Summary dated 04/30/26 provided by DON, for Resident #1 revealed Diagnoses: Obstructive and Reflux Uropathy, Acute Renal Failure. Document urinary output every shift.Review of Physician Telephone Order 03/17/26 for Resident #1 Date: 03/17/26 written by LVN A revealed OKAY TO START BLADDER TRAINING x 3 DAYS, THEN DC FOLEY AFTER four times a day for BLADDER TRAINING for 3 Days AND four times a day for Bladder Training for 3 Days.Review of 24-Hour Report Sheets revealed:-03/17/26 revealed 6am-2pm LVN A documented Resident #1 start bladder 3 days.-03/17/26 revealed 2pm -10pm LVN K documented start bladder training.Review of Nurse Medication admission Record dated March 2026 for Resident #1 revealed;-Okay to start Bladder Training x 3 days, then DC foley after four times a day for Bladder Training for 3 days. Start Date: 03/17/26 at 4:00 p.m. by LVN K. Clamp at 4:00 p.m., 10:00 a.m., 4:00 p.m. and 10:00 p.m. MAR documented Bladder Training was completed on 03/20/26 at 10:00 a.m. by LVN K.Review of Nurse Treatment Administration Record dated March 2026 for Resident #1 revealed output every shift:-03/23/26 at 6:00 a.m. - 2:00 p.m. shift 500 cc-03/23/26 at 2:00 p.m. - 10:00 p.m. shift n-03/23/26 at 10:00 p.m. -6:00 a.m. shift void x1-03/24/26 on the 6-2 shift was left blank by LVN A.Review of NTAR dated March 2026 for Resident #1 revealed Pain Assessment to be completed every shift:-03/24/26 on Day Shift LVN A documented no pain.Review of Medication Record dated March 2026 for Resident #1 revealed:-Start Date: 03/12/26 Tramadol HCL Oral Tablet 50 mg give 1 tablet by mouth every 8 hours as needed for pain.-03/24/26 Pain level 8 administered Tramadol HCL Oral Tablet 50 mg give 1 tablet by mouth administered by LVN T.Review of IDT Note dated 03/23/26 at 1:15 p.m. written by ADON F for Resident #1 revealed Urinary catheter intact.Review IDT Note dated 03/23/26 at 1:50 p.m. written by LVN A for Resident #1 revealed Late Entry: As per ordered, residents foley discontinued, resident tolerated procedure well, oncoming nurse informed to monitor urine output, resident calm, 0 c/o pain, will continue to monitor.Review IDT Note dated 03/24/26 at 6:00 a.m. written by LVN T for Resident #1 revealed Pt. voided x 1 wet brief.Review IDT Note dated 03/24/26 at 1:00 p.m. written by LVN A for Resident #1 revealed unable to urinate throughout shift and abdomen distended, informed NP, new order to reinsert foley, foley reinserted without any difficulties, observed no urine output with minimal blood output, resident's abdomen still distended. NP alerted, new order to flush foley with NS and for STAT ultrasound of bladder and abdomen, orders carried out, pending ultrasound to be done, oncoming nurse informed, resident calm, resting in bed, RP informed of new orders.Review of SBAR dated 03/24/26 at 1:30 p.m. written by ADON F for Resident #1 revealed Situation: Change in Condition: Abdominal pain. Diagnoses: Obstructive and Reflux Uropathy, Acute Renal Failure. New order for foley catheter and bladder ultrasound. Abdominal pain, distended abdomen. Does the resident have pain? Yes. Resident is on anticoagulant other than warfarin: No [sic].Review of IDT Note dated 03/24/26 at 4:43 p.m. written by LVN K for Resident #1 revealed, reported feeling nauseous and anxious. MD notified, new order for Zofran and a one-time dose of Xanax.Review of IDT Note dated 03/24/26 at 4:50 p.m. written by LVN K for Resident #1 revealed, vomited, so I gave another Xanax to help with his anxiety. ADON/MD.Review of IDT Note dated 03/24/26 at 5:02 p.m. written by LVN K for Resident #1 revealed, MD/NP was notified of abnormal ultrasound findings by staff. The resident reported abdominal pain, Blood noted in the foley. Ultrasound staff noted no Foley catheter was present and urine retention of 1500. new order was issued to send the resident to the hospital for evaluation and foley placement. 911 was called, and final ultrasound results are still pending.Review of the Radiology report dated 03/24/26 Ultrasound of Bladder for Resident #1 revealed, pre-void volume 1586 cc. No foley catheter identified in the bladder on today's study. Impression: Suspect urinary retention (a condition in which a person is unable to empty all the urine from the bladder), 1586 cc in bladder. A Foley catheter is not identified in the bladder on today's exam.Review of the Radiology report dated 03/24/26 Ultrasound of Abdomen for Resident #1 revealed, Impression: Moderate right-sided hydronephrosis (the swelling of one or both kidneys caused by a buildup or urine that cannot drain properly into the bladder).Review of IDT Note dated 03/24/26 at 5:23 p.m. written by LVN K documented Paramedics, arrived at the resident's room, and transported him to the hospital at 5:45 p.m. The family member was present, the Resident #1's Family Member was informed, and the ADON was made aware.Review of the EMS Care Report dated 03/24/26 for Resident #1 revealed, Symptoms Onset Date & Time: 03/24/26 at 5:23 p.m. Chief Complaint: Hematuria (having blood in the urine, originating from any part of the urinary tract, kidneys, bladder or urethra. It is a sign of an underlying issue, such as an infection, kidney stones, or injury) and Pain. Primary Symptom: Hemorrhage and pain. Medical History: Chronic Kidney Disease. Medications: Apixaban (an oral anticoagulant - blood thinner). Arrived at Patient: 5:23 p.m. Vital signs: B/P 70/42, heart rate 145, SpO2 83, respirations 18. Position: Sitting, opens eyes, alert, obeys commands. Exam/Assessment: Bleeding-Urethral Pain. Abdomen normal pain. Narrative: EMS responded to a long-term care facility. For a [AGE] year-old male presenting with gross hematuria noted within the urinary catheter collection bag. Upon arrival, the patient was conscious and alert, oriented to person place an event. The family member provided collateral history. Family member reported that an indwelling Foley catheter had been removed the previous day and replaced earlier that morning, noting that the procedure appeared to have been performed with excessive force, likely resulting in urethral trauma. Family Member further disclosed that the patient had an active prescription for an anticoagulant therapy, increasing concern for significant hemorrhage. The patient verbalized complaint of acute genital and lower abdominal pain. The patient continued to report severe, unrelenting pain and requested analgesic. Analgesic was administered per protocol. However, the patient continued to report inadequate pain relief. The patient was transported emergently to local hospital. Arrived at the emergency room at 5:43 p.m.Review of the facility's Provider Investigation Report dated 04/10/26 for Resident #1 completed by the facility's Administrator for an allegation of Resident Neglect revealed:-Review of email sent to facility's Marketer on 04/07/26 at 10:24 a.m. from Resident #1's family member attached to the Provider Investigation Report revealed, I am writing this letter because I know by now you are aware of the very traumatic and negligent incident that took place on March 24, 2026. I have not heard from you or anyone representing the facility. On March 24th [Resident #1] had been having problems urinating and he was getting very bloated. On this day, [LVN A] came into the room and proceeded to remove the foley catheter. The family member said they did not know where LVN A got the order to do that. When he did that, Resident #1 started bleeding from the tip. LVN A called the doctor and was instructed to re-insert the foley and order an ultrasound. LVN A was having problems re-inserting the foley and even commented that he was not even supposed to remove the foley in the first place. He kept re-inserting and forcing the foley in and causing bleeding. Another family member arrived and noted Resident #1 was bleeding, in severe pain, and vomiting. The family asked the nurse to call an ambulance and was immediately sent to the hospital ER. They immediately treated him and his pulse was 153 and his blood pressure was dropping. The resident was diagnosed with Traumatic Foley Insertion, Hematuria, Acute Sepsis, Acute UTI, and Anemia which required blood transfusion.-Review of a written statement written by CNA B in Spanish dated 04/08/26 translated by state surveyor, was attached to the Provider investigation report revealed, she was assigned to Resident #1 in the 300 Hall on 03/24/26 and the nurse was LVN A. During the day shift Resident #1 had no episode of incontinence, and she communicated this to LVN A throughout course of the day. Resident #1 said he felt the sensation to urinate but was unable to do so. I checked the brief on three occasions and he was dry. At 1:30 p.m. later, before the last round before the end of the shift, [LVN A] and I entered the room, and he inserted the urinary catheter.-Review of written statement written by ADON LVN Fated 03/25/26 attached to the Provider's Investigation Report revealed, on 03/24/26 LVN A called requesting assistance after receiving an order for Foley catheter insertion. The resident was informed of the procedure and provided consent. The resident's family member was present at bedside. Foley catheter insertion was performed without difficulty. The resident tolerated the procedure well and denied any pain or discomfort. No urine output was observed post insertion; however, minimal blood was noted in the Foley catheter. Abdomen was noted to be distended. NP G was notified of findings and issued new orders to flush the Foley catheter with normal saline, leave the catheter in place and obtain a stat ultrasound of the bladder and abdomen. The resident was informed of the new orders and verbalized understanding and agreement. Orders were initiated, with ultrasound pending at this time. Oncoming nurse was notified for continuity of care. The resident continues to deny pain or discomfort. Family Member remained at the bedside, and no concerns were voiced at this time.-Review of the Witness Statement written by CNA B on 04/28/26 documented she made this voluntary statement to state surveyor who had been properly identified as an investigator for the Texas Health and Human Services Commission (HHSC). On April 27, I was interviewed by state surveyor regarding a case involving [Resident #1] who had not had any episodes of incontinence during my shift on 6-2. When I arrived and went to check the resident and the report from the CNA from the previous shift told me that Resident #1 had not urinated and the catheter had been removed the day before and she proceeded to check the resident at 6:30 a.m., 9:30 a.m., 11:30 a.m. and 1:30 p.m. On two occasions I reported this to the nurse that when I went to check the resident during round the resident had not urinated. On the last round the resident's family member said that the resident still had not urinated, and I told the family member that I would report this to the nurse. That is when the nurse went to the room to insert the catheter. Prior to the catheter insertions the nurse had given the resident pain medication, and I was present when the procedure was completed and the nurse was always respectful and would ask [Resident #1] if he was having pain and to please let him know. [Resident #1] was very calm, with minimal discomfort. [ADON F] was aware of the situation and when the resident was sent to the hospital.-Review of the Witness Statement written by LVN A on 04/28/26 at 10:15 a.m. documented he made this voluntary statement to state surveyor who had been properly identified as an investigator for the Texas Health and Human Services Commission (HHSC). On 3/24/26 at 12:00 p.m. was informed by CNA that Resident #1 hadn't voided during shift. Assessed resident and noted abdomen distention. Resident calm during assessment. Informed NP, new order to reinsert foley catheter to resident. Using sterile technique, reinserted foley to resident with zero complications. Resident handled procedure without any distress. Noted no urine output when foley was inserted with minimal blood tinged fluid. Informed NP, new order to leave catheter in place, flush with normal saline and order KUB STAT. Orders carried out, resident and family member informed of new orders. ADON and DON informed, oncoming nurse informed of resident's update.During an interview and record review on 04/27/26 at 9:57 a.m. with LVN A he said he had checked Resident #1, one to three times during his shift on 03/24/26 and he had not assessed and/or asked the resident if he had voided. He said Resident #1 had not voiced any concerns to him on that day. He said he had not documented in the resident's clinical record when he had checked the resident during his shift. He said it was very important to assess the resident after the removal of the foley catheter to check if the resident had voided, because if the resident had not voided, that would be very concerning because the bladder could rupture if it got too full of urine. He said Resident #1 was oriented to person and place, required minimum assistance with ADLS, and was able to verbalize needs. He said he had reported to CNA B on 3/24/26 at approximately 7:00 a.m. that the foley catheter had been removed and to let him know if Resident #1 was not urinating. He said that the CNAs made rounds every two hours and that he remembered CNA B had only reported to him on that day at approximately 1:00 p.m. that Resident #1 had not urinated. He said the CNAs had been trained to immediately report changes of condition to the nurses. He said, I did not check Resident #1 during my shift on that day to see if he was urinating, I just took the CNA's words for it. He said that after CNA B had reported to him that the Resident #1 had not voided, he went to assess the resident and noted that the resident had abdominal distention, and he had called the NP to get orders to re-insert the foley catheter. He said that when he had reinserted the foley catheter there was no urine return. He said a family member, ADON F and CNA B, were in the room when he had inserted the foley catheter. He said he had notified the NP there was no urine return when he had inserted the urinary catheter and NP gave an order to flush the urinary catheter with normal saline and ordered a stat ultrasound of the abdomen and bladder to verify the placement of the urinary catheter. He said he had informed the DON of the situation on that day. He said that he had assessed Resident #1 and he was not having any symptoms of infection, no bloody or cloudy urine, no complaints of burning with urination, and the resident had not voiced to him any concerns about not being able to void. He said he had not documented his assessment in the resident's electronic clinical record or that when the ultrasounds of the bladder and abdomen were completed and that ultrasound results were still pending at the end of his shift. He said he was provided with 1:1 training on 4/07/26 by the DON on Foley insertion/Foley care. He said the licensed staff had been trained to document assessments in the resident's electronic record.During an interview on 04/27/26 at 10:49 a.m. with CNA B she said she was assigned to Resident #1 on 3/24/26 during the 6:00 a.m. - 2:00 p.m. shift and remembered that the resident did not have a foley catheter on that day at the start of shift. She said that the nurses do not give report to the CNAs unless it is something major, such as when a resident is at risk for falls. She said the CNAs get report from the night CNAs at the change of shift. She said, I remember that the night CNA reported to me on 03/24/26 at 6:00 a.m. at the change of shift that Resident #1 had a quiet night, but I do not remember if she told me if the resident had urinated during the night shift. She said she made rounds every two hours and that she remembered she had reported to LVN A on 3/24/26 at 6:30 a.m., 9:30 a.m., 11:30 a.m. and at 1:00 p.m. that the resident had not voided throughout the shift on that day and was complaining that he felt like urinating and the urine would not come out. She said LVN A had said, Ok let me talk to my ADON. She said the CNAs had been trained to immediately report any changes in condition to the nurses, because failure to report could worsen the resident's condition. She said she also remembered Resident #1's Family Member was in the room on that day when she had entered the resident's room at 1:00 p.m. to check if the resident's brief needed to be changed and to apply the moisture barrier on the resident's buttocks at which time she noted the resident's brief was clean and dry. She said she had immediately reported this to LVN A, and he had said that he needed to insert a foley catheter. She said LVN A had re-inserted the foley catheter on 3/24/26 at approximately 1:00 to 1:30 p.m. and asked her to let him know if the resident was not urinating. She said a family member, ADON LVN F and her were in the room when LVN A inserted the foley catheter and no urine came out. She said LVN A had also irrigated the catheter and no urine came out. She said the resident continued to complain of having abdominal discomfort and kept saying that he could not urinate.During an interview on 04/27/26 at 1:29 p.m., ADON LVN F said they had a Care Plan Meeting on 03/17/26 and that is when the family member voiced that they wanted the foley catheter to be discontinued. She said, I explained to the family member that Resident #1 first needed to be seen by the urologist as ordered when the resident was discharged from the hospital and that the urologist would be the one who would decide if the urinary catheter could be removed because of the resident's history of urinary retention. She said Urologist office staff were unable to schedule the pre-authorization due to not being approved by the resident's insurance. She said the staff at the Urologist office had said that they would call the facility to let them know when the appointment was scheduled. She said that they had not followed up on the status of the pre-authorization with the Urologist office staff. She said they had not documented any of this in the resident's electronic record. ADON LVN F said the family member had approached the NP during one of the visits and had asked for the foley catheter to be removed and the order was given by the NP to discontinue the foley catheter prior to the resident seeing the urologist. She said the NP was called by LVN A on 03/17/26 and gave the order to start Bladder Training x 3 days, then to discontinue the foley and monitor urinary output x 24 hours. She said that she was not aware that the nurse got an order to discontinue the foley catheter. She said the urinary catheter was removed on 3/23/26 by LVN A as ordered by the NP. She said that she did not know if the nurses had monitored the resident's output x 24 hours according to physician's orders. She said she was in the room on 03/24/26 when LVN A had re-inserted the foley catheter and noted multiple beads of blood on the meatus (the external opening of the urethra (a tube that carries urine from the bladder out of the body). She said, He stopped and placed a call to the NP and was given a new order for an Ultrasound of the bladder, check if the foley was in place and to flush the foley catheter with normal saline. She said that she was not present when LVN A had irrigated the foley catheter.During an interview on 04/27/26 at 4:18 p.m., the DON said that she was not aware that CNA B had reported to LVN A four times during the day shift on 03/24/26 that Resident #1 had not voided since 6:30 a.m. and was complaining of abdominal pain and of being unable to urinate. She said that LVN A should have immediately assessed Resident #1 and notified the physician and/or NP. She said LVN A was responsible for checking if Resident #1 had not voided after the foley catheter was removed. She said the nurses made rounds every two hours and should check and assess the residents as needed. The DON informed the state surveyor that their corporate staff had said that they did not have a policy and procedure on Bladder Training with Foley Catheter. The DON said she had not found any documentation on Bladder Training with a foley catheter that had been completed for the licensed staff. She said, I checked everywhere and did not find any training for the nurses on Bladder Training.During a telephone interview on 04/27/26 at 3:48 p.m., family member said Resident #1 had not voided throughout the morning on 03/24/26 and was complaining of abdominal pain and kept saying that he felt like urinating and was unable to urinate. She said LVN A had inserted the foley catheter on 03/24/26 and there was no urine return. The family member said Resident was sent to the emergency room at the family's request and were informed that the resident had had a traumatic foley insertion and had a large amount of urine in his bladder. The family member reported that the resident had hemorrhaged and was given blood transfusions. The family member said the Resident #1 was admitted to ICU and was in critical condition. The family member said Resident #1 had been discharged from the hospital and was at home and receiving Home Health Services. During an interview on 04/27/26 at 4:00 p.m. with the DON in the presence of the Administrator, it was revealed that she had confirmed with the facility's corporate staff that the only policy they had was on Catheter Care, Urinary revised in July 2024 and that they did not have a policy and procedure on Bladder Training with foley catheter.During a telephone interview on 4/27/26 at 4:45 p.m. with NP G she said she could not remember when the bladder training had been completed for Resident #1. She said an order was given for Bladder Training on 03/17/26 x 3 days and to discontinue the foley catheter after the Bladder Training was completed, and to monitor the resident's output x 24 hours for urine retention. She said LVN A had sent her a text message on 03/24/26 at 12:08 p.m. to report Resident #1's foley catheter had been removed on 03/23/26 in the afternoon and Resident #1 had not voided during his shift on 03/24/26. She said she replied to his message and gave an order to insert the foley catheter back. She said she was aware that Resident #1 had a history of urinary retention and the foley should not have been removed on 03/23/26 if the resident was having urinary retention. She said LVN A had reported to her that there was a little bit of blood noted when catheter was inserted and she gave an order to flush the catheter and gave an order for an ultrasound of the bladder and the abdomen on that day. She said the ultrasound revealed Resident #1 was retaining a lot of urine. She said that if the catheter was not in the bladder, there would be no urine return and if there was an obstruction, the nurse needed to remove the catheter and try again, and if the second attempt was unsuccessful, LVN A needed to notify the physician/NP right away. She said, I don't know what happened on that day. She said that the potential complication of urinary retention could cause the bladder to rupture and the resident would need to have a permanent suprapubic (is a soft tube placed directly into the bladder through a small opening in the lower abdomen, just above the pubic bone) She said she could not remember if the family member had approached her and asked to discontinue the foley catheter. She said she was not aware that the resident had an order to be seen by the urologist within 10-14 days when discharged

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 one of four residents (Resident #4) reviewed for Enhanced Barrier Precautions.-The facility failed to implement their policy on Enhanced Barrier Precautions (EBP) for Resident #4 who had indwelling medical devices.-The facility failed to ensure that PPE was readily available for the staff to use when providing direct care to those residents on EBP.This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organism (MDROs).The findings included:Record review of the Face Sheet dated 04/27/26 for Resident #4 revealed Original admission Date was 12/24/25 and readmission date was 04/17/26.Review of the History and Physical dated 12/25/25 revealed [AGE] year-old male with past medical history of Multiple Sclerosis (is a chronic autoimmune disease where the immune system mistakenly attacks the myelin sheath, the protective covering of nerve fibers in the brain and spinal cord. This damage disrupts nerve signals, causing various symptoms like numbness, weakness, balance problems, vision issues, and cognitive difficulties, as the messages between the brain and body are slowed or blocked), BPH with urinary retention (an enlarged prostate had grown large enough to squeeze the tube that carries urine out of the body, making it impossible or very difficult to empty the bladder, leading to pain and need for a catheter) with chronic foley catheter (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or various medical reasons), frequent UTIs (is a common bacterial infection in the system that makes and stores urine. It causes painful, frequent urges to urinate, burning sensation, cloudy urine, or lower stomach pain. It occurs when bacteria enter the urinary tract), neuromuscular neurogenic bladder dysfunction (is a loss of bladder control caused by nerve damage, meaning the brain, spinal cord, and bladder cannot communicate properly resulting in inability to store or empty urine correctly, leading to leaks, urgency, or difficulty urinating). Review of the Significant change in status MDS dated [DATE] for Resident #4 revealed, Reentry date 04/17/26. BIMs Score 14 (cognitively intact), functional limitation in range of motion to upper/lower extremities. Wheelchair. Toileting-substantial/maximal assistance. Bed Mobility- substantial/maximal assistance. Indwelling catheter. Diagnoses: Neurogenic Bladder ( (occurs when nerve damage disrupts the communication between the brain and the bladder), Multiple Sclerosis (an autoimmune disease where the body's immune system mistakenly attacks the central nervous system, damaging the protective covering of nerve cells) Review of the Care Plan dated 03/05/26 for Resident #4 revealed: Resident Has a suprapubic catheter r/t Multiple sclerosis, Neuromuscular dysfunction of bladder, And overactive bladder. Interventions: Change catheter every month or as needed for MD orders. Monitor and document intake and output. Monito for signs and symptoms of discomfort on urination and frequency. Monitor for signs and symptoms of UTI Pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change of behavior, change in eating patterns.Observation on 04/27/26 at 11:35 a.m. revealed Resident #4 was lying in bed awake; HOB elevated 45 degrees. It was observed that resident had an indwelling catheter and was draining light yellow urine. He was able to answer questions by moving his head and/or index finger for yes and no. The urinary drainage bag was placed in a dignity bag and was hanging on the side to the bed. There was an EBP sign posted on the door to the entrance to the room. There were isolation, gowns, and gloves in the room.During an observation and interview on 04/27/26 at 11:37 a.m. with LVN C assigned to Resident #4 revealed resident had a suprapubic catheter and a G-Tube. There was a sign posted on the door for Enhanced Barrier Precautions. Upon entering the room, the nurse did not wash her hands, did not use hand sanitizer, did not put on gloves and a gown prior to uncovering the resident and demonstrating to the state surveyor that the resident did not have a dressing on the stoma where the G-Tube was inserted in the stomach. The stoma had moderate amount of dried yellow drainage. She said, I have not cleaned the site yet. I do not place any type of dressing on the stoma because it makes him itch. She demonstrated to the surveyor that the resident had a suprapubic catheter and did not have a dressing on the stoma. She said they had been trained to use a gown and gloves when they provide direct care with resident that have any type of indwelling devices and/or history of drug-resistant organisms to prevent cross contamination and prevent the spread of infections. She said, I forgot to put on the PPE when I entered the resident's room to show you the stoma sites.During a second interview on 4/27/26 at 12:38 p.m. with Resident #4, it revealedat he could talk and answer questions. He said that the nurses never cleaned the G-Tube site or the suprapubic site. He said that the nursing staff never used the gowns and gloves when they entered the room to assist him with personal care.During an interview on 4/27/26 at 12:42 p.m. with CNA D working in the 100 Hall said that the residents that had an EBP sign posted on the door had some type of indwelling device such as a catheter, feeding tube, pressure ulcer or some type of infection. She said they had been trained to put on a gown and gloves when they provided direct care to prevent cross contamination and the spread of infection. She said the PPE was kept by the entrance to the rooms. During an observation and interview on 04/29/26 at 4:01 p.m. with CNA U and CNA V revealed that they did not always know which residents were on EBP especially when they get new admissions. They said they were rotated to different assignments daily and that made it very hard to know the needs of each resident. They said for example in room [ROOM NUMBER] there were two residents and they did not know which one of the residents was on EBP. They said the PPE should be by the entrance to the resident's room. There was a sign posted on the door to the entrance of the room that documented Stop Enhanced Barrier Precautions. There was a box of gloves by the entrance to the room and there was no PPE (gowns and masks) stored in the resident's drawers. They also checked the cabinets in the hallway and there was no PPE readily available for use.During an observation and interview on 04/29/26 at 4:12 p.m. with ADON LVN I said the staff needed to follow EBP on those residents that had G-Tube, foley, wounds, and any type of indwelling devices. She said the nursing administration and the nurses checked during rounds that the nursing staff were following EBP when providing direct care to those residents that needed to be on EBP to prevent cross-contamination and the spread of infection. The state surveyor asked the ADON to show her where the PPE was stored. The ADON entered room [ROOM NUMBER], there was an EBP sign posted on the door to the entrance of the room that documented Stop Enhanced Barrier Precautions. [NAME] said they have small, square plastic bins where they store the gowns and mask. She checked the closet, dresser drawers and there were no gowns and masks in the room. The Resident in B bed told the ADON that the CNAs had used all the gowns in the morning.During an observation and interview on 04/29/26 at 4:16 p.m. with the DON said EBP precautions was used when providing direct care to those that had foleys, G-Tubes, PICC lines and wounds. She said ADON LVN F was the Infection Control Preventionist and she posted the EBP signs on the doors and stocked the PPE in the resident rooms. She said the PPE was kept in small square containers in the residents' room and were stored in the drawers or in the closet. She said she randomly checked that the staff followed the EBP protocols to prevent the spread of infection and cross contamination. It was observed that there was an EBP sign posted on the door in room [ROOM NUMBER]. The DON attempted to enter room [ROOM NUMBER] to check if there was PPE in the room and that resident did not allow the DON to enter the room. During an observation and interview on 04/29/26 at 4:20 p.m. in room [ROOM NUMBER] with DON revealed, there was an EBP sign posted on the door to the entrance of the room. The DON entered the room and pulled out the plastic bin out of the drawers and said, there were no gowns and mask in the room. The DON said Resident #6 had a suprapubic catheter and was on EBP.During an observation and interview on 04/29/26 at 4:24 p.m. in room [ROOM NUMBER]-B with DON revealed, there was an EBP sign posted on the door to the entrance of the room. The DON entered the room and pulled out the plastic bin out of the drawers and said, There were no gowns in the room.During an interview on 04/29/26 at 4:27 p.m. with ADON LVN F revealed EBP signs were posted on the doors for those residents that have history of drug-resistant organisms, any type of indwelling devices, and wounds. She said the nursing administration made constant rounds to check the nursing staff were following EBP protocols to prevent cross contamination and the spread of infection. She said that she and central supply re-stocked the PPE on the units and in the residents' rooms. She said the staff were trained to let her and/or central supply where they had run out of PPE. The surveyor requested copies of Infection Control Policies and Policy on EBP. During an interview on 04/29/26 at 4:31 p.m. with ADON LVN F said the CNAs should immediately let the DON/ADONs, or central supply, that they were out of PPE so they can restock the PPE.During an observation and interview on 04/29/26 at 4:35 p.m. with ADON LVN F, took the state surveyor to the 400 Hall to show her the medical supply storage room where they stored PPE for the staff to restock as needed. She said all the staff knew the combination of the storage room. Upon entering the supply room, she said, We do not have any PPE stored in the storage room today but there was PPE in the central supply room.During an observation and interview on 4/29/26 at 4:36 p.m. with ADON LVN F revealed there were only three boxes of surgical masks that had 50 masks in a box and two cases of gowns stored in the Central Supply Room. She said central supply ordered PPE weekly.During an interview on 4/29/26 at 4:45 p.m. with Central Supply W he said he ordered PPE weekly on Mondays/Tuesdays and was delivered on Wednesday or Thursday. He said ADON LVN F re-stocked the PPE on the nursing units. He said that in the event the orders were not delivered on time, he could borrow PPE from his sister facilities.During an interview on 4/29/26 at 4:55 p.m. with the Administrator and DON revealed Central Supply ordered PPE on a weekly basis and shipments were delivered to facility on Thursdays or Fridays. The administrator said that if shipments were delayed, they could always borrow PPE from their sister facilities in town. She said that she was not aware of PPE not being readily available for the staff to use when residents were on EBP.Review of facility's policy and procedure on Enhanced Barrier Precautions Revised February 2025 provided by ADON LVN F ADON/Infection Preventionist on 04/29/26 revised on February 2025 revealed, Policy Statement: Enhance Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Policy Interpretation and Implementation: Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the transmission of multidrug resistant organisms to residents. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise. Gloves and gowns are applied prior to performing the high contact resident care activities (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-risk contact resident care activities requiring the use of gowning gloves for EBPs Include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief or assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, etc.); and wound care (any skin opening requiring a dressing). EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with a CDC targeted or epidemiologically important MDROs. EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds. (ie., pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds), not shorter lasting wounds such as skin breaks or skin tears. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs), indwelling urinary catheters, feeding tubes and tracheostomy tubes. Peripheral Ivy catheters are not considered an indwelling medical device for purposes of EBPs. EBPs Remain in place for the duration of the resident stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted on the door or wall outside the resident room indicating the type of precaution and PPE required. PPE EBP's is available outside or inside the residents' rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. The state surveyor requested copies of the facilities policy and procedures on Infection Control from ADON LVN F ADON/Infection Preventionist on 04/29/26 and were not provided prior to exit on 04/30/26.The state surveyor requested copies of invoices for weekly orders for PPE from Central Supply W on 04/29/26 and were not provided prior to exit on 04/30/26.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 residents (Residents #1) reviewed for medical records.- The facility failed to ensure LVN A documented in Resident #1's electronic clinical record on 3/24/26 when he assessed the resident for urinary retention and signs and symptoms of urinary tract infection throughout the morning shift.- The facility failed to ensure LVN A documented in Resident #1's electronic clinical record on 3/24/26 when he completed the bladder irrigation.These failures place residents at risk of having incomplete and accurate clinical records.Findings included:Closed Record review of the Face Sheet dated 04/27/26 for Resident #1 revealed an admission date of 03/09/26 and discharged date to acute care hospital on [DATE] at 10:03 p.m.Review of History & Physical dated 03/10/26 written by attending physician for Resident #1 revealed [AGE] year-old male with past medical history of, anxiety (a feeling of fear, dread, unease, or worry, often accompanied by physical symptoms like a rapid heartbeat or tension) , PTSD (a mental health condition triggered by experiencing or witnessed a terrifying, life threating or traumatic event), and right flank pain. Physical Exam: Genitourinary: Non-distended bladder. Summary of Findings: Anxiety, Abdominal Pain. Plan: Psych consult if worsening symptoms. The H&P did not document resident had a history or Obstructive and Reflux Uropathy (is a blockage preventing urine from leaving. It can lead to infection, high blood pressure and permanent scaring if not treated. Reflux Uropathy is urine flowing backward from the bladder to the kidneys), Acute Kidney Failure (The sudden loss of kidney function, typically occurring within hours or days. It causes a rapid buildup of waste products and toxins in the blood and disrupts fluid/electrolyte balance).Review of the Physician Progress Note dated 03/24/26 at 7:39 p.m. written by the physician after Resident #1 had been sent to the hospital via EMS at 5:36 p.m. revealed, Reason for Visit: Follow up and no urine output. History: This is a [AGE] year-old male with a past medical history significant for anxiety, PTSD. Current Status: Patient with no urine output following foley catheter removal. Noted abdominal distention, though patient denied discomfort or pain. Foley catheter was reinserted due to failure to void. Upon insertion, no urine output was obtained; a blood clot was noted in the catheter upon removal nursing staff were instructed to reinsert the foley and irrigate with normal saline. Following reinsertion and irrigation, there was still no urine output. A STAT bladder ultrasound was ordered, which demonstrated approximately 1500 ml urinary retention and evidence of left-sided hydronephrosis (the swelling of the kidney caused by a backup of urine). Due to persistent obstruction despite catheter reinsertion and irrigation, and significant retention with upper tract involvement, the patient was transferred to the ER for urgent urologic evaluation and definitive Foley placement. Date of Service: 3/24/26.Review of Hospital paperwork dated 3/25/26 for Resident #1 revealed, Chief Complaint: Patient coming from long term care facility for frank blood in urine from foley exchange yesterday. Per family, pt. had a Foley catheter exchange yesterday and now has approximately 100 cc of frank blood in the foley bag. Presented with markedly distended bladder and non-draining Foley. History of Present Illness: prior urinary retention(inability to completely empty the bladder, or in some cases, to pass urine at all)/bladder outlet obstruction (is a partial or complete blockage at the base of the bladder that slows or stops urine from exiting the body), and chronic anticoagulation (taking blood thinner medication on a long-term basis to prevent dangerous blood clots from forming or getting larger) presents from nursing facility with urinary retention, gross hematuria (blood in the urine that is visible to the naked eye), and shock (the body's severe, toxic overreaction to an infection). Resident was recently hospitalized from [DATE] to 03/09/26 urinary retention/bladder outlet obstruction. He now presents from nursing facility after a traumatic foley catheter that was not draining, with markedly distended bladder and gross hematuria. On arrival he was noted to be tachycardic (an abnormal fast resting heart rate), tachypneic (rapid and shallow breathing), and in increased respiratory distress/work of breathing, which improved after Foley exchange and bladder decompression. Approximately 45 minutes prior to arrival, pt. became increasingly lethargic (having absolutely zero energy, feeling incredibly sluggish, and being unable or unwilling to move or do anything). Diagnoses: Septic Shock due to Acute Urinary Tract Infection (a sudden bacterial infection in the urinary system), Acute blood loss anemia (a sudden and dangerous drop in red blood cells caused by rapid bleeding) transfuse supportively as needed. Bladder outlet obstruction, Gross hematuria. Admit to Intensive Care Unit in critical but stable condition with urology consultation.Review of admission MDS dated [DATE] for Resident #1 revealed Entry Date: 03/09/26 from acute care hospital. Clear speech makes self-understood and understand others. BIMS Score 15 Cognitively intact. Indwelling catheter. Active Diagnosis: Anxiety Disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), Renal Failure (is when the kidneys stop working properly, are unable to filter waste, remove excessive fluid, and balance chemicals in the blood), Obstructive Uropathy. High Risk Medications: Antianxiety, antidepressant, anticoagulant.Review of the Care Plan dated 03/10/26 for Resident #1 revealed Resident had an indwelling catheter r/t obstructive and reflux uropathy. Interventions: Catheter as ordered. Monitor and document intake and output as per facility policy. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor for pain and discomfort due to catheter. Monitor/record/report to MD signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating pattern.Review of Physician Order Summary dated 04/30/26 provided by DON, for Resident #1 revealed Diagnoses: Obstructive and Reflux Uropathy, Acute Renal Failure. Document urinary output every shift.Review of Physician Telephone Order 03/17/26 for Resident #1 Date: 03/17/26 written by LVN A revealed OKAY TO START BLADDER TRAINING X3DAYS, THEN DC FOLEY AFTER four times a day for BLADDER TRAINING for 3 Days AND four times a day for Bladder Training for 3 Days.Review of Nurse Treatment Administration Record dated March 2026 for Resident #1 revealed output every shift:- 03/24/26 on the 6-2 shift was left blank by LVN A.Review IDT Note dated 03/24/26 at 1:00 p.m. written by LVN A for Resident #1 revealed unable to urinate throughout shift and abdomen distended, informed NP, new order to reinsert foley, foley reinserted without any difficulties, observed no urine output with minimal blood output, resident's abdomen still distended. NP alerted, new order to flush foley with NS and for STAT ultrasound of bladder and abdomen, orders carried out, pending ultrasound to be done, oncoming nurse informed, resident calm, resting in bed, RP informed of new orders.Review of the EMS Care Report dated 03/24/26 for Resident #1 revealed, Symptoms Onset Date & Time: 03/24/26 at 5:23 p.m. Chief Complaint: Hematuria (having blood in the urine, originating from any part of the urinary tract, kidneys, bladder or urethra). It is a sign of an underlying issue, such as an infection, kidney stones, or injury) and Pain. Primary Symptom: Hemorrhage and pain. Medical History: Chronic Kidney Disease. Medications: Apixaban (an oral anticoagulant - blood thinner). Arrived at Patient: 5:23 p.m. Vital signs: B/P 70/42, heart rate 145, SpO2 83, respirations 18. Position: Sitting, opens eyes, alert, obeys commands. Exam/Assessment: Bleeding-Urethral Pain. Abdomen normal pain. Narrative: EMS responded to a long-term care facility. For a [AGE] year-old male presenting with gross hematuria noted within the urinary catheter collection bag. Upon arrival, the patient was conscious and alert, oriented to person place an event. The family member provided collateral history. Family member reported that an indwelling Foley catheter had been removed the previous day and replaced earlier that morning, noting that the procedure appeared to have been performed with excessive force, likely resulting in urethral trauma. Family Member further disclosed that the patient had an active prescription for an anticoagulant therapy, increasing concern for significant hemorrhage. The patient verbalized complaint of acute genital and lower abdominal pain. The patient continued to report severe, unrelenting pain and requested analgesic. Analgesic was administered per protocol. However, the patient continued to report inadequate pain relief. The patient was transported emergently to local hospital. Arrived at the emergency room at 5:43 p.m.During an interview on 04/27/26 at 9:57 a.m., LVN A said he had checked Resident #1, one to three times during his shift on 03/24/26 and he had not assessed and/or asked the resident if he had voided. He said Resident #1 had not voiced any concerns to him on that day. He said he had not documented in the resident's clinical record when he had checked the resident during his shift. He said it was very important to assess the resident after the removal of the foley catheter to check if the resident had voided, because if the resident had not voided, that would be very concerning because the bladder could rupture if it got too full of urine. He said he had reported to CNA B on 3/24/26 at approximately 7:00 a.m. that the foley catheter had been removed and to let him know if Resident #1 was not urinating. He said that the CNAs made rounds every two hours and that he remembered CNA B had only reported to him on that day at approximately 1:00 p.m. that Resident #1 had not urinated. He said the CNAs had been trained to immediately report changes of condition to the nurses. He said, I did not check Resident #1 during my shift on that day to see if he was urinating, I just took the CNA's words for it. He said that after CNA B had reported to him that the Resident #1 had not voided, he went to assess the resident and noted that the resident had abdominal distention, and he had called the NP to get orders to re-insert the foley catheter. He said that when he had reinserted the foley catheter there was no urine return. He said a family member, ADON F and CNA B were in the room when he had inserted the foley catheter. He said he had notified the NP there was no urine return when he had inserted the urinary catheter and gave an order to flush the urinary catheter with normal saline and ordered a stat ultrasound of the abdomen and bladder to verify the placement of the urinary catheter. He said he had informed the DON of the situation on that day. He said that he had assessed Resident #1 and he was not having any symptoms of infection, no bloody or cloudy urine, no complaints of burning with urination, and the resident had not voiced to him any concerns about not being able to void. He said he had not documented his assessment in the resident's electronic clinical record or when the ultrasounds of the bladder and abdomen were completed and that ultrasound results were still pending at the end of his shift. He said he was provided with 1:1 training on 4/07/26 by the DON on Foley insertion/Foley care. He said the licensed staff had been trained to document assessments in the resident's electronic record.During an interview on 04/27/26 at 10:49 a.m., CNA B said she was assigned to Resident #1 on 3/24/26 during the 6:00 a.m. - 2:00 p.m. shift and remembered that the resident did not have a foley catheter on that day at the start of shift. She said that the nurses do not give report to the CNAs unless it is something major, such as when a resident is at risk for falls. She said the CNAs get report from the night CNAs at the change of shift. She said, I remember that the night CNA reported to me on 03/24/26 at 6:00 a.m. at the change of shift that Resident #1 had a quiet night, but I do not remember if she told me if the resident had urinated during the night shift. She said she made rounds every two hours and that she remembered she had reported to LVN A on 3/24/26 at 6:30 a.m., 9:30 a.m., 11:30 a.m. and at 1:00 p.m. that the resident had not voided throughout the shift on that day and was complaining that he felt like urinating and the urine would not come out. She said LVN A had said, ok let me talk to my ADON. She said the CNAs had been trained to immediately report any changes in condition to the nurses, because failure to report could worsen the resident's condition. She said she also remembered Resident #1's Family Member was in the room on that day when she had entered the resident's room at 1:00 p.m. to check if the resident's brief to needed to be changed and to apply the moisture barrier on the resident's buttocks at which time she noted the resident's brief was clean and dry. She said she had immediately reported this to LVN A, and he had said that he needed to insert a foley catheter. She said LVN A had re-inserted the foley catheter on 3/24/26 at approximately 1:00 to 1:30 p.m. and asked her to let him know if the resident was not urinating. She said a family member, ADON LVN F and her were in the room when LVN A inserted the foley catheter and no urine came out. She said LVN A had also irrigated the catheter and no urine came out. She said the resident continued to complain of having abdominal discomfort and kept saying that he could not urinate.During a telephone interview on 4/27/26 at 4:45 p.m., NP G said she could not remember when the bladder training had been completed for Resident #1. She said an order was given for Bladder Training on 03/17/26 x 3 days and to discontinue the foley catheter after the Bladder Training was completed, and to monitor the resident's output x 24 hours for urine retention. She said LVN A had sent her a text message on 03/24/26 at 12:08 p.m. to report Resident #1's foley catheter had been removed on 03/23/26 in the afternoon and Resident #1 had not voided during his shift on 03/24/26. She said she replied to him and gave an order to place it back. She said she was aware that Resident #1 had a history of urinary retention and the foley should have not being removed on 03/23/26 if the resident was having urinary retention. She said LVN A had reported to her that there was a little bit of blood noted when catheter was inserted and she gave an order to flush the catheter and gave an order for an ultrasound of the bladder and the abdomen on that day. She said the ultrasound revealed Resident #1 was retaining a lot of urine. She said that if the catheter was not in the bladder, there would be no urine return and if there was an obstruction, the nurse needed to remove the catheter and try again, and if the second attempt was unsuccessful, LVN A needed to notify the physician/NP right away. She said, I don't know what happened on that day. She said that the potential complication of urinary retention could cause the bladder to rupture and the resident would need to have a permanent suprapubic. She said she could not remember if the family member had approached her and asked to discontinue the foley catheter. She said she was not aware that the resident had an order to be seen by the urologist within 10-14 days when discharged from the hospital on [DATE]. She said, if I had known, I would have followed the prescriber's order.During an interview on 4/28/26 at 10:30 a.m., LVN A said he had reinserted the foley catheter on 03/24/26 per NP's order, due to Resident #1 having abdominal distention. He said Resident #1 never voiced any concerns to him on 03/24/26 about having abdominal discomfort and not being able to void. He said he had sent a Group Text to the physician and the NP, on 03/24/26 and the NP had responded and gave an order to reinsert the foley catheter. He said there was no urine return when the catheter was inserted and when the catheter balloon was inflated, there was watery tinged drainage with blood on the meatus. He said he had notified the NP, and she gave an order to leave the catheter in place and irrigate the foley with [NAME] saline. He said he had irrigated the foley catheter as ordered with normal saline and had not documented in the resident's clinical record. He said the Ultrasound results had been sent to the facility after he had completed his shift. He said the resident was sent to the hospital during the evening shift. The state surveyor requested a copy of the screen shot of the text message sent to NP G on 03/24/26 by LVN A.Review of the screen shot of the text message sent to NP G on 03/24/26 at 12:08 p.m. by LVNA revealed, Resident #1 's foley was d'cd yesterday afternoon. He hasn't voided on my shift yet. NP responded at 12:10 p.m., place it back if he doesn't void.Review of the facility's policy and procedures on Charting and Documentation revised July 2017, provided by the DON revealed, Policy Statement: All services provided to the resident, progress towards the care plan goals, or any change in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: Documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations; Medications administered; Treatment or services performed; Changes in the resident's condition. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Entries may only be recorded int the resident's clinical record by licensed personnel (e.g., RN, LVN, physician, therapist, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided; the name and title of the individual(s) who provided the care; the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment; notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.

Based on observation, interview and record review the facility failed to maintain food service practices under sanitary conditions by not ensuring dietary staff performed proper hand hygiene during food handling and meal service. The facility failed to ensure dietary staff A performed good hand hygiene within the context of food handling and sanitation.This failure could place residents at risk of cross contamination and the potential transmission of infectious organisms. Findings included: An observation on 01/14/2025 at 12:10 PM during lunch Dietary staff A was seen using her cell phone before the lunch trays were about to be distributed. Dietary Staff A quickly put her phone away in her pocket and walked up to the food line table to begin placing trays onto carts to be distributed to the residents. Dietary Staff A placed 4 trays onto a cart when LVN A asked Dietary staff A to place an object on the door to prevent it from closing. Dietary staff A went and grabbed a food can and placed it at the bottom of the door to prop open the door. She then went back to the table line and started placing food trays onto carts again. Dietary Staff A was not seen performing hand hygiene during these two transactions. In an observation on 01/14/2025 at 12:20 PM Dietary staff A still had not performed hand hygiene and was asked to provide food covers for residents' trays in which she handled with both hands. She was then asked to provide a resident with salsa and ground chicken, in which she handed to LVN A. She then proceeded to continue with food tray line and placed food trays on the food cart.In an observation on 01/14/2025 at 12:22 PM Dietary staff A walked away into the back of the kitchen where she could not be seen. When she returned to the food line she was seen with gloves on. Unaware if Dietary Staff A performed hand hygiene prior to placing gloves on. In an interview on 01/14/2025 at 12:50 pm the Dietary manager stated, Dietary staff aids were supposed to wash their hands prior to handling food trays on the food line and staff were not allowed to touch anything else after that. If they need to touch anything else, then the food tray staff need to go back and wash their hands before returning to the food tray line. What Dietary Staff A did was not okay for her to do. Dietary Manager stated he needed to do an in-service with her. Dietary Manager stated Dietary Staff A was relatively new and was trained on hand hygiene and when to perform hand hygiene when going to grab something else and then returning to the food line. The risk of her not performing hand hygiene during her handling all the objects she did was a risk for infection control. In an interview on 01/14/2026 at 01:20 PM, DON stated Dietary Staff A should have worn gloves or performed hand hygiene. After handling anything other than food and placing it on the floor would require hand hygiene. The risk was cross contamination and infection.In an interview on 01/14/2026 at 03:11 PM, Administrator stated when staff go from one modality or station to the other, they should be washing their hands. If staff handle nonfood items and then return to the food line, they should be washing their hands before getting to the food line. The risk was cross-contamination, or food poisoning.In an interview on 01/15/2026 at 12:39 pm, Main [NAME] stated he had been employed at the facility for approximately 2 years and 7 months and consistently practiced proper hand hygiene. He further stated that the facility provides hand hygiene training at least every six months and instructs staff especially new hires, that if they touch anything outside of the food tray line, they must immediately perform hand hygiene prior to continuing food service. Failure to wash or sanitize hands after touching non-food items or after handling multiple trays posed a risk to infection control and cross-contamination control or cross contamination.Review of facility policy titled Handwashing/Hand Hygiene revision date October 2023, updated 01/2025, stated The facility considers hand hygiene the primary means to prevent the spread of healthcare- associated infections.1.) All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2.) All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.

Based on 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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, interventions and timeframes for how staff will meet Resident #1's needs related to her history and risk for dehydration. This failure could place residents at risk of a decline in health due to no care plan being implemented. Record review of Resident #1's face sheet dated 01/14/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted to facility on 12/31/2025. Resident #1's diagnoses included type 2 diabetes with hyperglycemia (high amount of glucose in blood), Dehydration (body loses more fluid then its intaking), and Acute kidney failure (kidneys stop working). Record review of Resident #1's MDS dated [DATE], reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #1 had impairment to one side of upper extremity (Shoulder, Elbow, Wrist, hand), and impairment to both sides of lower extremities (Hip, Knee, Ankle, foot). Record review of Resident #1's Physician's Order Summary Report dated 01/15/2026, revealed that Resident #1 did not have an order for maintaining medical diagnosis for dehydration. Record review of Resident #1's hospital history and physical dated 06/12/2025, revealed a [AGE] year-old female diagnosed with diabetes mellitus, TIAs (Temporary stoke from brief blood flow blockage to the brain), hyperlipidemia (high levels of fats), and Dehydration (loss of water and salts for normal body function). Record review of Resident #1's Care Plan dated 01/15/2026, revealed that Resident #1 did not have any care plans for her medical diagnosis of dehydration. In an interview on 01/14/2026 at 01:20 PM DON stated Resident #1's care plan was discussed during her care plan meetings, specifically for her dehydration. In the care plan meeting it was brought up about the consistency of the fluids. In the hospital records, it was recommended at the hospital level for a G-tube to be placed because she disliked the thickening of the Nectar, but the family member declined it. Resident #1 had a diagnosis of Dysphagia (difficulty swallowing), she could drink thin liquids, but she drank the honey Nectar due to her Renal Failure. DON reviewed Resident #1's care plans and stated that the care plans had nothing regarding dehydration and how to prevent it. The risk of no care plans for dehydration would result in the resident dehydrating again and being readmitted into the hospital. The DON stated that it's the responsibility of the MDS nurse for reviewing residents' care plans. DON stated there's a regional person that also reviews the assessment and usually they'll report back to the Administrator if there was anything wrong with a resident's care plan, in which it was not reported for Resident #1. In an interview on 01/14/2026 at 02:30 PM, MDS nurse stated that care plans were developed when a resident first admitted into the facility, then every quarter and with any change of condition. Nursing staff take responsibility as well for overlooking care plans and were placed into PCC correctly. MDS nurse stated there was no specific order for Resident #1's medical diagnosis for dehydration but there was no risk since there was a care plan order for fluid imbalance which could indicate for either at risk for renal failure or dehydration. The care plan stated a goal for Risk for altered Fluid balance which stated intervention/task evaluate blood pressure and Evaluate resident/Representative on methods to relieve dry mouth while maintaining fluid restriction. MDS nurse stated, those are all interventions on the resident's profile that could be used for dehydration, so it is addressed on there. In an interview on 01/14/2026 at 03:11 pm Administrator stated that the responsibility for care plans would be the MDS nurses and the RNs, they go over them and make sure it is all correct and then they sign off on the care plans as well as the QRM who overlook as well to make sure of its input correctly. Since the resident had a medical diagnosis of dehydration there should have been a care plan due to her history of hospitalization due to dehydration and UTIs. The risk was if one doesn't know what symptoms or interactions to look for would affect the health of the resident. Nurses were trained upon hire and come up with their Relias training (learning management designed for healthcare workers to meet regulatory compliance, reduce risk, and improve employee perfromace) or when in-services were conducted. Nursing staff have had in-services regarding fluid intake in the last month, or month and a half and admin had instructed the managers in the morning meetings to be checking to make sure all pitchers have water and have been offering residents water consistently to prevent any dehydration at the facility. Jelly drops have also been ordered in which were used for Resident #1 as well but unsure if she liked them or not. The facility had been very focused on hydration. Review of facility policy titled Care plans, Comprehensive Person-Centered revision date March 2022, stated A comprehensive, Person-Centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy interpretation and implementation:7.) The comprehensive, person-centered care plan:b.) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:C.) Includes the residents stated goals upon admission and desired outcomes; e.) reflects currently recognized of practice for problem areas and conditions.10.) When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms or triggers.11.) Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.12.) The interdisciplinary team reviews and updates the care plan:c.) when the resident has been re-admitted to the facility from a hospital stay: and

Based on observation, interview and record review, the facility failed to provide ADL care for 2 (Resident # 94 and Resident #97) of 12 residents reviewed for ADLs. The facility failed to maintain Resident # 94 and Resident #97's fingernails clean and free from debris.This failure could place residents who required assistance with ADL's and resided on secure units of unmet care needs. Findings included:Resident #94 Record review of Resident #94's admission Record dated 09/05/2025 revealed a 63- year-old female with an initial admission date of 07/28/2023 and a readmission date of 12/09/2024. Record review of Resident #94's Diagnosis Information dated 09/05/2025 revealed diagnosis of hemiparesis to right side due to cerebral vascular accident. Record review of Resident #94's Quarterly MDS dated [DATE] revealed a BIMS of 11 indicating moderate cognitive impairment. Section GG indicated resident was dependent meaning helper does all of the effort when preforming personal hygiene. Record review of Resident # 94's Care Plan revised on 08/21/2025 revealed resident had an ADL self-care deficit related to disease process and hemiparesis to right side due to previous cerebral vascular accident. An observation and interview on 09/02/2025 at 11:47am with Resident # 94 in Resident # 94's room revealed resident with long dirty fingernails to left hand. She stated that she wanted them cleaned and trimmed. Resident #97 Record review of Resident # 97's admission Record dated 09/04/2025 revealed a [AGE] year-old male with an admission date of 08/19/2025. Record review of Resident #97's Diagnosis Information dated 09/04/2025 revealed diagnoses of unspecified dementia. Record review of Resident # 97's admission MDS dated [DATE] revealed a BIMS score of 05 indicating severe cognitive impairment. Section GG indicated that resident needed set up or clean up assistance meaning helper provides verbal cues and/or touching/ steadying and/ or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently when preforming personal hygiene. Record review of Resident #97's care plan dated 08/20/2025 revealed resident had a self-care performance deficit related to dementia. An observation on 09/02/2025 at 10:14am in Resident # 97's room revealed residents' fingernails to be long, about one inch off of nail bed on hands bilaterallyIn an interview on 09/04/2025 at 11:13 AM with CNA G reported that CNAs were responsible for cleaning and trimming the nails of residents who were not diabetic. CNA G stated that if a resident was diabetic nursing was responsible for cutting their nails due to adverse risks to the resident's health. CNA G reported that CNAs were still responsible for maintaining the cleanliness and filing nails down no matter a resident's diagnosis. CNA G stated that if a resident denies having their nails clipped, nurses must talk to the resident and document the conversation. CNA G reported that the ADON and DON were responsible for ensuring staff were tending to residents' nail care. In an interview on 09/05/2025 at 9:39 AM, with LVN H, reported CNAs were responsible for filing, cleaning, clipping nails for nondiabetic residents. LVN H stated this task should be completed daily and reviewed by all nursing and CNA staff. LVN H confirmed the last in service for nail care was three months prior. LVN H reported potential outcomes for residents could result in resident breaking their skin and becoming infected from dirty nails. LVN H added that long nails could pose a threat to staff and other residents as well. LVN H closed that from a dignity perspective, residents could feel unheard and neglected if staff did not cut their nails after prompting. In an interview on 09/05/2026 at 1:30 p.m., with DON, she stated that residents' fingernails were trimmed as needed., she stated that CNA's would check if nails needed trimming when residents were showered. She stated that CNAs could trim residents' fingernails if they were not diabetic. She stated that it was CNA's and nurses' responsibility to ensure residents fingernails were kept trimmed and clean. She stated that risks of long fingernails included poor hygiene and infection since residents touch their faces and mouths. Record review of facility policy and procedure titled Fingernails/Toenails, Care of revised on 02/2018 read in part Nail care includes daily cleaning and regular trimming. Proper nail care can aid in prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 14 residents (Resident #38 and Resident #72) reviewed for pharmacy services.Resident #38 and Resident #72 had an unlabeled clear plastic cup at bed side with Zinc Oxide pomade (skin ointment) and a tongue depressor in it, exposed, and within reach of other residents.This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. Findings included:Record review of Resident #38's admission record dated 09/03/25 revealed she was admitted on [DATE].Record review of Resident #38's history and physical dated 08/12/25 revealed a [AGE] year-old female diagnosed with primary osteoarthritis (a chronic degenerative joint disease referred to as wear-and-tear arthritis, as it typically develops over time due to the breakdown of the protective cartilage that cushions the ends of bones in a joint) to right ankle and foot, pain in joints, chronic kidney disease, difficulty walking, wheelchair bound and bilateral foot drop (a medical condition characterized by the inability to lift the front part of both feet).Record review of Resident #38's admission MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating his cognition was intact. The MDS indicated under section GG, for Functional Abilities, the resident required moderate assistance with toileting hygiene, shower, lower body dressing, and putting on footwear, sit to stand and transfers to toilet and shower. Record review of Resident #38's care plan dated 08/28/25 revealed Resident # 38 was allergic to Latex and the care plan called for interventions on recording other allergies in the resident records. Record review of Resident # 72's admission record dated 09/02/25 revealed she admitted on [DATE].Record review of Resident # 72's history and physical dated 07/13/25 revealed a [AGE] year-old female diagnosed with urinary tract infection, severe obesity, Parkinson's disease (a chronic, progressive neurological disorder that primarily affects the nervous system and motor functions), and hypertension. Record review of Resident # 72's admission MDS dated [DATE] revealed he had a BIMS score of 15 indicating her cognition was intact. The MDS under section GG, for functional abilities, revealed the resident required moderate assistance with upper body dressing. She required substantial assistance with toileting hygiene, lower body dressing and putting on footwear, and she was dependent on staff for bathing. Record review of Resident # 72's care plan, dated 07/18/25, revealed Resident # 72 had a potential for decreasing ADLs related to increased tremors due to Parkinson's disease. The care plan indicated interventions to assist with ADLs as needed which included maintaining her current level of functioning in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. In an observation and interview on 09/02/2025 at 9:44 AM with Resident #72, the resident was working on a puzzle while sitting on her wheelchair. Behind the resident, there was a nightstand and on top of the nightstand, there was a clear and unlabeled cup; the cup contained white cream with a tong depressor inside. The resident stated that the cup contained a cream that was applied to her by the CNAs to help with a rash she had for wearing her briefs. Resident #72 stated that usually staff would leave the cream like that to reuse whenever she was assisted with changing her briefs through the day. In an observation and interview on 09/02/2025 at 9:57 AM with Resident #38, the resident was in bed watching TV. To the right side of the resident on her nightstand, there was a clear plastic cup with white cream residues and a tong depressor inside. Resident #38 stated that the cream was applied to her earlier that morning while being changed to treat a rash she developed on her skin due to wearing her briefs. Resident #38 stated she did not know how long the cup had been there, but that CNAs left cups with the cream on top of her nightstand regularly. In an interview on 09/02/2025 at 10:35 AM with the CMA, she stated the contents of the plastic cup was antifungal cream which was applied to the residents to treat or prevent skin rash. CMA said staff should not leave any medication or cream at the resident's side table uncovered and unlabeled. The CMA stated that staff were expected to throw the cup containing any residual cream into the trash. The CMA stated there could be a risk of infection if the medication gets contaminated because it was left uncovered and if it was then used or applied onto a resident. She stated there was also a risk for another resident who was confused and wandered into that room and ate the cream which would make them sick to their stomach or spread infection. In an interview on 09/02/2025 at 10:45 AM with LVN C, he stated that the contents of the clear and unlabeled cup was zinc oxide which was for preventing brief rash on those residents who wore them. LVN C said staff were expected to dispose of any cream left in the cup once it was applied to the resident. LVN C explained the cup and medication was supposed to be covered to prevent contamination and said that if the contents of the cup were used on the resident, and it had been contaminated either with dust or debris, there was a risk of infection and contamination. LVN C stated if the oxide zinc was contaminated, and it was applied to a resident's rash; it could make it worse and cause more discomfort to the residents. In an interview on 09/03/2025 at 2:49 PM with the DON, she stated the contents of the clear and unlabeled cup was oxide zinc to treat rashes and for skin protection which was applied to residents when the residents are changed from briefs. The DON stated It was not correct to leave any medications at bed side because it was within reach of the residents, and anyone could get their hands on it. The DON stated there was a risk for the medication to get contaminated, and if it was applied to the resident, the rash could get worse, and it could evolve into major infection affecting a resident's health and well-being. In an interview on 09/03/2025 at 2:58 PM with the IP, she stated the cream should not be left at bedside because it was unlabeled and there was no way of knowing what it was. The IP said there was a risk of particles falling into the cream or medication which could contaminate it, and if the resident had a rash and they applied it to the affected area, it could potentially make it worse. The IP explained there was also a risk for another resident to wander into the room and confuse the content of the cup with food and they could ingest the contents which could result in residents getting sick from their stomach. In an interview on 09/04/2025 1:51 PM CNA A, she stated the cup was more than likely containing zinc oxide which was used to prevent and treat rashes on residents. She stated it was not acceptable to leave the cup at bed side because the medication was exposed and not labeled. She stated there was a risk of the cream being contaminated for being exposed, and if it was used on a resident, there was a risk of infection or making the rash worse. In an interview on 09/04/2025 at 2:16 PM with CNA B, she stated the clear cup contained [NAME] oxide and explained it should not be exposed or uncovered and unlabeled. CNA B stated the medication should be a smaller portion to prevent wasting the medication and if there was any left in the cup, it should be thrown into the trash. CNA B stated if the medication was left open and exposed, it could be confused as food and a resident could ingest it which could make them sick. CNA B stated that there was a risk of contamination of the contents of the cup and if it was applied to a resident, the rash could get infected or worsen. In an interview on 09/05/2025 at 2:03 PM with the Administrator, she stated that medications should never be left at bedside of the residents. She stated there was a potential risk for the medication to be contaminated if anything was to fall inside of the cup and if applied to the resident having a rash, the rash could potentially get worse. She stated there were also confused residents within the facility who could wander into the room and if the medication was within reach, they could potentially put it into their mouth, and it could lead to infection or sickness to their stomach. In an interview on 09/03/25 at 10:15 AM with the DON revealed the facility did not have any policies addressing leaving medications at residents' bedside.

Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 3 (Residents #5, 29, and 58) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident # 5, 29 and 58's oxygen concentrator filter free from lint and dust on 09/02/2025 This failure could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include: Resident #5 Record Review of Resident # 5's admission Record dated 09/05/25 revealed a [AGE] year-old male with an original admission date of 07/10/2025 and a readmission date of 06/23/2025. Record Review of Resident # 5's Medical Diagnosis record dated 09/05/2025 revealed medical diagnosis of Acute respiratory failure with hypoxia (lungs fail to adequately provide oxygen to the body, resulting in low blood oxygen levels). Record Review of Resident #5's Quarterly MDS dated [DATE] revealed Section O special treatments, procedures and programs noted resident on oxygen therapy. Record Review of Resident #5's Care Plan revised on 07/17/2025 revealed the resident was receiving oxygen therapy. An observation on 09/02/2025 at 9:58am, in Resident #5's room revealed resident lying in bed receiving oxygen via a nasal canula at 2 liters per minute. The oxygen concentrator air filter was observed with dust and lint. Resident #29 Record Review of Resident # 29's admission Record dated 09/05/2025 revealed an [AGE] year-old male with an admission date of 08/24/25. Record Review of Resident # 29's History and Physical dated 08/25/2025 revealed medical diagnosis of Acute respiratory failure with hypoxia (lungs fail to adequately provide oxygen to the body, resulting in low blood oxygen levels).Record Review of Resident # 29's 5-day MDS dated [DATE] revealed a BIMS score of 00, indicating a severe cognitive impairment. Section O special treatments, procedures and programs noted resident on oxygen therapy.Record Review of Resident #29's care plan revised 08/27/2025 revealed the resident was receiving oxygen therapy.An observation on 09/02/2025 at 10:14am, in Resident #29's room revealed resident lying in bed receiving oxygen via a nasal canula. The oxygen concentrator air filter was observed with dust and lint. Resident #58 Record Review of Resident # 58's admission Record dated 09/05/2025 revealed an [AGE] year-old female with an original admission date of 02/05/2025 and a readmission date of 06/20/2025. Record Review of Resident #58's History and Physical dated 06/19/2025 revealed a medical diagnosis of history of pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Record Review of Resident #58's Quarterly MDS dated [DATE] revealed Section O Special treatments, Procedures, and Programs revealed Resident # 58 was receiving oxygen therapy. Record Review of Resident #58's care plan revised 07/17/2025 revealed resident had a potential for altered respiratory status/difficulty breathing related to chronic pulmonary edema and history of pneumonia. Interventions included administration of oxygen as per doctor's orders. An observation on 09/02/2025 at 11:15 am in Resident #58's room revealed resident lying in bed receiving oxygen via a nasal canula. The oxygen concentrator air filter was observed with dust and lint.In an interview on 09/04/2025 at 11:30 am with LVN F revealed that any nurse can check the oxygen concentrator air filter especially if it starts to beep, the air filter is the first thing that is checked to ensure there was no obstruction. She stated that air filters were checked on and cleaned every Sunday night on the 10pm - 6am shift. She stated that the risks of having dirty air filters was that the oxygen was not delivered the way it is supposed to be delivered. She stated that there was an Inservice on keeping oxygen filters clean approximately a couple of months ago. In an interview on 09/05/2025 at 1:30 pm with DON revealed that she was not sure who was responsible for cleaning the oxygen concentrator filters. She stated that she believed that the central supply person was the person that would monitor the air filters along with the nurses on the floor. She stated that dirty air filters interfere with the function of the machine itself. She stated that the noise of the concentrator could get loud, which could be uncomfortable for residents. She stated that it also affects the quality of oxygen being delivered to residents. She stated that there had been no Inservice to staff regarding clean air filters. Record Review of the Oxygen Concentrator Manual provided by the facility, revealed in part Cleaning of outer cabinet recommended interval of 7 days. Cleaning of air filter recommended cleaning interval of 7 days.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for two (Residents #7, and #9) of eight residents who were reviewed for dignity.The facility failed to provide adequate access to disposable briefs, and wipes for Resident #9.The facility failed to provide mechanical lift nets to their assigned resident within a reasonable timeframe causing the resident to stay in bed for prolonged period of time.The facility failed to promote dignity while dining when staff did not serve Resident #7 lunch almost 15 minutes after their tablemates were served during initial dining room observation on 09/02/25.These is failures could placed the residents at risk of poor self-esteem and decreased self-worth.Findings included:Briefs & WipesRecord review of Resident #9's face-sheet dated 09/02/25, revealed a [AGE] year-old female with an admission date 07/18/24, and re-admission date of 01/30/25.Record review of Resident #9's Quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating resident was cognitively intact.Record review of Resident #9's history and physical dated 06/25/25, revealed a medical diagnosis of: Chronic Obstructive Pulmonary Disease (a lung and airway disease that restrict your breathing), schizophrenia, congestive heart failure, depressive disorder, anxiety disorder, and fibromyalgia (a chronic condition causing pain throughout your muscles and soft tissues).Record review of Resident #9's care plan with revised date 06/21/25, included resident was at risk for UTI's and skin breakdown, which noted interventions for staff including using incontinent briefs as needed. In an interview on 09/02/25 at 10:46 AM with Resident #9, she stated there was a limit of briefs provided to residents for every shift. She stated staff were always looking in other resident rooms looking for briefs or wipes on a daily basis because they do not have access to supplies. Resident #9 stated the nursing facility should be sufficiently supplied due to briefs and wipes being basic rights. She stated it was harder for the weekend staff to gain access to supplies, so the delay in care was longer. Resident #9 stated she felt the delay in care was a dignity issue.An observation on 09/05/25 with the ADON was conducted of the Central Supply room. A surplus of wipes, briefs, and supplies were observed.In an interview on 09/04/25 at 11:40AM with LVN E, they stated that wipes and briefs had been harder to obtain for approximately 3 months, and exceptional difficulties occurred over the past month. LVN E confirms residents who are not provided adequate supplies or have trouble obtaining them infringes on the resident's rights. LVN E denies any history of resident's stock piling supplies in the past to set on this new policy.In an interview on 09/04/25 at 01:41 PM with CNA A, she stated if supplies finished, they were to request more with Central Supply because they would only provide certain amounts of briefs and wipes on the floor for each shift. She stated the concern had been rising since approximately 3 months, and it was reported to the ADON's and the DON before. She stated the Administrator was also aware but there had been no resolution or change. CNA A stated the administration were responsible for ensuring staff were well supplied and stocked for the shift. She stated it was for patient care, and supplies being secured in the Central Supply closet was delaying care for residents.In an interview on 09/04/25 at 02:09 PM with CNA B, she stated there were not enough briefs which was reported to the nursing supervisor. She stated Central Supply was responsible for supplying floor staff with materials such as briefs and wipes. She stated the administration were responsible for monitoring the supplies and its' amount. She stated the risk of residents not having their briefs or wipes readily available were skin breakdown, or a dignity issue.In an interview on 09/05/25 at 10:50 AM with LVN H, she stated there was a daily issue with nursing staff having wipes and briefs on the floor. She stated this could be a risk for residents, by contributing to an increase in Urinary Tract Infections. LVN H stated there were briefs and wipes secured in Central Supply, which only limited staff had access. She stated Central Supply provided a certain number of briefs and wipes to each hall. She stated the facility did not take into account the residents with conditions that caused increase in urination, or accidents, such as dementia. She stated this was a dignity issue for residents as the residents had to wait prolonged time during change which can cause skin irritation.In an interview on 09/05/25 at 01:09 PM with the DON, she stated she provided the code to the supply closet where all briefs and wipes were located to supervisor staff of each shift. She stated the last call for access from staff was approximately 2-3 weeks ago. She stated there were risks for residents if their needs were not met, such as basic needs, which included a dignity issue.In an interview on 09/05/25 at 11:33 AM with Central Supply, he stated the facility placed orders for supplies on Mondays or Tuesday, which is authorized by the Administrator. He stated the Administrator reviewed all his supply order requests before submitting, and the Administrator would add or subtract supplies. He stated he was advised by the Administrator of corporate's weekly budget for supplies was strict, which was to not exceed $1,500 for briefs and wipes. He stated the order then went through corporate for final review before the supply request was submitted. He stated the corporate office also added or subtracted supplies. He stated he was notified by various staff of their concern of not being provided enough supplies. He stated these concerns were reported to the Administrator, and if he could request more, he would ensure the residents have the sufficient number of briefs and wipes on the floor. He stated he provided a certain amount of briefs and wipes on the floor by placing them in a cabinet in each hall. He stated he stocked them in the morning when he started his shift, which was approximately 6:30 AM, and again at 3:00 PM. He stated the staff could call him for access to the Central Supply room and the last time was 1 month ago. He stated the risks for residents included a dignity issue.Mechanical Lift NetIn an interview on 09/02/25 at 10:55 AM with Resident #9, she stated she was told the week before, unsure of exact date, by an unknown person of being advised to wait to be transferred out of her bed until the staff could find a mechanical lift net. Resident #9 stated it was prolonged waiting, which was upsetting to her.In an interview on 09/04/25 at 01:34 PM with CNA A, she stated the nursing facility bought and assigned a mechanical lift net for each resident that required them. She stated if the resident's mechanical lift net became soiled, it would need to be washed through the laundry services which should only take a few hours. She stated if residents were to be in bed for prolonged periods of time, it could pose a risk for pressure ulcers, or depression. She stated there was an issue with having enough supplies on the floor which had been reported to the DON and the Administration, but there were no reported changes in supply amount.In an interview on 09/05/25 at 11:53 AM with the Housekeeping Supervisor, he stated the process for washing Mechanical Lift Net included using the washing machine, but the nets required to be air dried. He stated he was aware of reports by staff that dirty Mechanical Lift Nets were being left in the rooms when protocol called for nursing staff to immediately place them in dirty linen to expedite the cleaning process. He stated he reported this issue with the Administrator which she ordered more nets one month ago. He stated staff were in-serviced on process to dispose dirty Mechanical Lift Nets to Laundry. He stated the risks of Mechanical Lift Nets not being readily available for the residents included bed sores, and delay of care since residents could not be transferred without the net.In an interview on 09/05/25 at 01:21 PM with the DON, she stated she was not currently aware of a mechanical lift net shortage issue. She stated there were risks for not transferring residents within their scheduled times, such as isolation for the resident, or skin integrity issues. She stated the CNA's and nurses were responsible for monitoring their residents throughout their shift and transferring the residents in and out of bed.In an interview on 09/05/25 at 02:13 PM with the Administrator, she revealed she had ordered mechanical lift nets at the end of July 2025. She stated, if the issue was that mechanical lift nets were not being washed immediately, or placed in laundry for it to be washed, then it could delay the washing process. She stated this could delay the residents' care by delaying them getting transferred out of bed. The Administrator stated the risks for residents not being transferred in or out of bed as ordered, included the risks for pressure sores, or weakening of the muscles which can contribute to risk for falls. She stated nursing was responsible for ensuring mechanical lift nets were getting to laundry so the nets could get washed, and the Laundry department was responsible for washing/drying resident belongings, including the Mechanical lift net, in a timely manner.Dining roomRecord review of Resident #7's face-sheet dated 09/02/25 revealed resident was a [AGE] year-old male with an admission date 11/03/23.Record review of Resident #7's Quarterly MDS dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment.Record review of Resident #7's history and physical dated 08/07/25, revealed a medical history of bipolar disorder (a chronic mental condition that is characterized by extreme highs and extreme lows), dementia (cognitive decline that can affect activities of daily living such as behaviors, thinking, and memory), and cognitive communication deficit.Observation on 09/02/25 of initial lunch meal serving to residents, revealed 3 of 4 residents were served at 12:30 PM. Resident #7, one of the four residents at the table, was observed waiting for his lunch tray and stated he would like a tray. This surveyor informed staff and Resident #7 was served his lunch tray at 12:43 PM. 2 of 3 of his tablemates were observed finished with their meal when Resident #7 was served.In an interview on 09/04/25 at 01:28 PM with CNA A, she stated the nurses were responsible for confirming all residents in the dining room were served during mealtimes. CNA A stated the nurses confirm which residents were in the dining room to be served during mealtimes, versus residents whose trays were sent to their rooms. She stated the risk for the resident being served after his tablemates was a self-esteem issue as it could make them feel bad to eat last.In an interview on 09/05/25 at 11:09 AM with LVN F, she stated all nursing staff were responsible for ensuring residents had their trays during mealtimes. LVN F stated CNA's pass out trays to residents while nurses confirm trays for residents. She stated the risk for residents being served at different times could affect the resident's self-esteem.In an interview on 09/05/25 at 01:05 PM with the DON, she stated the nurses and CNA's were responsible for ensuring trays were served to residents in a timely manner. She stated that herself, and the ADON's, or the charge nurses, assisted with serving trays as needed. The DON stated the risk for the resident included a dignity issue.In an interview on 09/05/25 at 02/07/25 with the Administrator, she stated there were multiple staff members responsible for ensuring all residents were served their meal tray. She stated that included the charge nurse, and herself. She stated it was important for residents to be served within a small timeframe because it can cause the resident not eating, to be uncomfortable watching other residents eating.Record review of Nursing Facility's policy 'Resident Rights' read in part: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: A. a dignified existence; B. be treated with respect, kindness, and dignity; C. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for one (Resident #13) of six residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #13 to address Resident's urinary indwelling foley catheter.This failure could place residents at risk for unmet care needs, complications with urinary catheter use, and a decline in their overall health and quality of life. Findings Include:Record review of Resident #13's face sheet dated 09/03/25 revealed resident was an [AGE] year-old female with an admission date 06/02/25.Record review of Resident #13's Quarterly MDS dated [DATE] revealed a BIMS score of 1, indicating severe cognitive impairment. The Quarterly MDS, under Section H-Bladder and Bowel, revealed Resident #13 had an indwelling catheter.Record review of Resident #13's history and physical dated 08/11/25 revealed a medical history of: Acute Urinary retention (sudden involuntary inability to completely empty the bladder causing discomfort and can lead to complications) postoperatively requiring Foley catheter placement (a flexible and sterile tube through the urethra, helps continuously drain urine from the bladder), AKI (Acute Kidney Injury, a decline in kidney function causing a decline in the kidney's function of filtering waste from blood), and Dementia.Record review of Resident #13's care plan [SP1] did not include or address the resident's indwelling foley catheter.During an observation on 09/02/25 at 10:45 AM, Resident #13 was in bed with her foley catheter placed on the side of bed. In an interview on 09/05/25 at 11:12 AM with LVN F, she stated MDS nursing were responsible for the care plan. She stated care plans were evaluated quarterly, and as needed. She stated the residents having care plans without information addressing the residents' conditions such as a foley catheter meant the staff would not be able to provide care specific to the catheter.In an interview on 09/05/25 at 12:05 PM with the MDS Nurse, she stated nursing was responsible for compiling the resident's care plan regarding their medical needs such as a foley catheter. She stated MDS Nursing staff monitored the residents' care plans every 3 months, or quarterly. The MDS Nurse stated residents' foley catheters needed to be included in the care plan because it was the plan of care centered to the resident including their conditions. She stated there was a risk resident would get improper care if their conditions were not care-planned.In an interview on 09/05/25 at 01:01 PM with the DON, she stated care plan's purpose was for staff to provide the resident's plan of care specific to the resident. The DON stated resident conditions, such as resident's having an indwelling foley catheter, needed to be included in residents' care plan. She stated MDS nursing were responsible for care plans, which were reviewed upon admission and every 3 months or as needed. The DON stated the risks for the residents of their conditions such as indwelling catheters included in their care plan, was potential for incomplete patient care.In an interview on 09/05/25 at 02:11 PM with the Administrator revealed care plans were the responsibility of all departments such as nursing, social services, therapy, and dietary departments all include their plans of care for the resident. The Administrator stated IDT (interdisciplinary team) meetings were conducted weekly and they evaluated residents' care plans. She stated the risks of incomplete care plans included inaccurate care for residents such as staff being unaware of monitoring for symptoms of infection, for example for foley care.Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, with no date read in part: Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It also noted, The comprehensive, person-centered care plan: c. includes the resident's stated goals upon admission and desired outcomes; e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection 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 # 63) of fourteen residents observed for infection control in that: Resident #63's catheter drainage collection bag was left on the floor, and the wheel of her side table was on top of the bag. This deficient practice could result in cross contamination, spread of infection and could result in a urinary tract infection.The findings included:Record review of Resident #63's admission record dated 09/03/2025, revealed the resident was admitted on [DATE].Record review of Resident #63's history and physical revealed the resident was an [AGE] year-old female with a past medical history of significant dementia (a decline in memory and other thinking skills), chronic kidney disease (long-term loss of kidney function), atrial fibrillation (an irregular and often rapid heart rate), coronary artery disease (a buildup of plaque in the arteries that supply blood to the heart). Record review of Resident #63's admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 0 indicating the resident's cognition was severely impaired. The MDS revealed under section GG, for functional abilities, the resident needed maximal assistance (where the helper does more than half the effort) with eating, oral, toileting, showering and dressing. Under section H, for Bladder and Bowel, MDS indicated under urinary continence, the resident was occasionally incontinent, and under bowel continence, the resident was always incontinent. The MDS revealed for the care area assessment (CAA) summary, the resident triggered for urinary incontinence and indwelling catheter (a thin, flexible tube that is inserted into a person's body and left in place for a period of time to drain fluids, such as urine from the bladder, or to deliver medication).Record review of Resident #63's care plan dated 08/01/2025 revealed the resident was at risk of urinary tract infections related to incontinent bladder and bowel and stated the goal was for the resident to be in a clean, dry state to prevent complications of incontinence by checking and changing the resident at regular intervals. It revealed that Resident #63 was at risk for edema (swelling caused by excess fluid in the body's tissues), SOB (shortness of breath), fluid volume overload (a condition where the body has too much water and sodium), related to a diagnosis of renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluids).In an observation and interview on 09/02/2025 at 10:35 AM with the CMA, Resident #63's catheter drainage collection bag was observed on the floor, and the wheel of her side table was on top of the bag. CMA stated the side table's wheel was dangerously clamping the bag, posing a risk for it to tear and spill. The CMA stated this would create an infection control issue, and if someone stepped on the spilled contents, they could slip and sustain a fall or injury. The CMA explained that the resident could contract an infection because the bag was on the floor, risking contamination. In an interview on 09/02/2025 at 10:45 AM with LVN C, he stated the bag was improperly touching the floor, and the side table's wheel shouldn't be on top of the foley bag. LVN C said the bag could tear, spilling its contents and creating an infection risk for the resident, staff and visitors in the facility due to contamination.In an interview on 09/03/2025 at 2:53 PM with the DON, she stated it was unacceptable for the foley bag to be on the floor, where it was being pinched by the wheel from the resident's side table. The DON said this created a pathway for bacteria to enter, which could cause an infection to the resident. The DON stated the spilled contents could also lead to a potential fall hazard to anyone in the facility who entered the room and would create an infection hazard if the resident had infections that could be transmitted to other residents.In an interview on 09/03/2025 at 3:03 PM with the IP, she stated the foley bag was not supposed to be touching the floor. She said the wheel on top of the bag could tear it and spill its contents creating an infection control issue. The IP said foley bags should never touch the floor because germs could get in or out, causing an infection and potentially leading to the resident becoming septic. In an interview on 09/04/2025 at 1:23 PM with CNA A, she stated the foley bag was touching the floor, creating a risk of contamination to the resident. She said the wheel of the side table was on top of the bag and could tear it, spilling the contents. CNA A explained this could create a cross-contamination risk, as staff move throughout the facility and could carry infections to other places. In an interview on 09/04/2025 at 2:21 PM with CNA B, she stated the foley bag was directly on the floor, creating a risk for infection control. She said foley bags should never touch the floor because of the risk of infection to the resident. She also stated that with the wheel on top of the bag, if the resident was repositioned, staff might not notice the bag was underneath the wheel, which could be very painful for the resident if the tubing was pulled. CNA B said there was a risk of the bag being torn by the wheel, spilling its contents and creating an infection control issue. She said the floors could become contaminated, and staff could transport bacteria to the entire facility, and even to their families' homes on their shoes if the resident had an infection. In an interview on 09/05/2025 at 2:10 PM with the Administrator, she stated that the foley bag should never touch the floor because of the risk of infection to the resident from bacteria on the floor, which could worsen their condition. She also stated there was a risk of infection to other residents, staff, and visitors if the bag was torn by the side table wheel, and its contents spilled. The Administrator said there was also a fall risk if the contents spilled, and someone walked through it.Record review of the facility's policy and procedure updated in July 2024 titled Catheter Care, Urinary, read in part: PurposeThe purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Controlb. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 of 6 residents (Residents #1, and #21) reviewed for call lights. The facility failed to ensure resident call lights were within reach for 2 Residents #1, and #21. This failure placed residents at risk of having their needs unmet when they are unable to contact staff. Findings included: Resident #1 Record review of Resident #1's admission record dated 09/05/2025 revealed a 74- year-old female with an original admission date of 10/17/2024 and a readmission date of 05/04/2025. Record review of Resident #1's history and physical dated 8/18/2025 revealed diagnoses of dementia and seizure disorder. Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 03 indicating severe cognitive impairment. Record review of Resident # 1's care plan revised on 11/08/2024 revealed resident was at risk for injury related to seizure disorder, she was receiving anti-convulsant medications and was at risk for side effects, adverse reactions and toxicity of medication. Nursing intervention included keeping call light within reach. In an observation and interview on 09/02/2025 at 2:36 p.m., during initial screening, call light was observed on the floor while resident was asleep in the bed. At 2:58PM CNA D entered the room briefly and located resident asleep and proceeded to leave room. CNA D was asked about call light placement for Resident #1. Upon entering the room, call light was still found on the floor. CNA D confirmed this was not appropriate and the call light should've been within the resident's reach. CNA D confirmed when she initially checked on the resident, she did not ensure call light was within reach before exiting room. Resident # 21 Record review of Resident #21's admission record dated 09/05/2025 revealed an 80- year-old female with an original admission date of 12/29/2023 and a readmission dated of 06/27/2025. Record review of Resident #21's history and physical dated 07/28/2025 revealed diagnoses of hemiparesis (partial paralysis of one side of the body), and acute right sided weakness. Record review of Resident #21's quarterly MDS dated [DATE] revealed a BIMS of 02 indicating severe cognitive impairment. Record review of Resident # 21's care plan revised on 01/21/2025 revealed resident had a potential for selfcare deficit in ADLs related to history of cerebral vascular accident with right sided hemiparesis. Nursing interventions included keeping pad call light within reach. An observation and interview on 09/02/2025 at 2:04 PM revealed Resident #21 required a touch pad call light for communication purposes which was out of reach for the resident during initial observation. Call light pad was attached to the top right of the bed clipped to the bedliner. Resident had limited range of motion on right side and could not reach call light if needed. Interview with CNA D, revealed the call light was out of reach for the resident, based on condition. In an interview on 09/04/2025 at 11:33 AM with LVN C revealed Call lights were used for residents to communicate needs. He stated that the call light was supposed to be kept within reach of the resident without them having to extend their arms. A risk of the call light not being within reach would be needs could go unanswered, they could fall trying to get the call light, they could feel distress and feel abandoned. He stated that call lights were answered as soon as possible and nurses and CNA's were to round every 2 hours or sooner. He stated that angel rounds were done every morning by supervisors to ensure call lights were within reach. In an interview on 09/05/2025 at 11:25 AM with the ADON revealed call light was used to notify staff that a resident needed help or was in need of something. It was used as a form of communication. She stated that any staff member could respond to a call light and notify specialized staff to address resident's needs. Nursing staff and CNAs were required to reposition call light if found out of reach of resident. She stated that angel rounds were done between 8-9AM conducted by department heads as a way to provide an extra set of eyes to residents. The ADON stated charge nurse, ADON, DON were responsible for ensuring call lights were being responded to. She stated that pad call lights were used as intervention for individuals with limited range of motion and varied on individuals with their care plan, range of motion and severity of paralysis. She reported August 2025 was the last in-service done on call lights. She stated that residents could be in danger if they did not have access to the call light, especially in nonverbal residents because it was a vital form of communication. She stated that it was a potential for residents to be neglected. The ADON stated the resident could feel anxious, anger, embarrassment dependent on situation. In an interview on 09/05/2025 at 11:51 AM with the DON she stated a call light was a device used for a patient to request assistance. She stated that call lights were supposed to be placed within residents' reach meaning as long as it was within arm reach. She stated that everybody was responsible for ensuring call lights were within reach. All staff were capable of positioning call lights in reach. She stated rounds were made every two hours, allowing more frequent opportunities to ensure call light is within reach, review environment. Residents with severe contractors and limited ranges of motion. Residents with call pads should have it within their reach. The DON educate staff on call lights on clipping call lights to residents' bed. In both photos call light is not in reach. Residents could feel anxious, potential for neglect if a resident doesn't have call light in reach. In an interview with the Administrator on 09/05/2025 at 12:15 PM revealed, the call light was used to notify staff that the resident needed something, it was used for an array of things to substantiate communication. She stated that call lights should be within easy reach of the residents. She stated that as long as the arm extremity can reach it without torso movement it was considered within reach. She stated that all staff were responsible for answering call lights to include the varying departments. All staff and department head's that conducted angel rounds were responsible for ensuring the call light was within reach. She reported rounds were done every two hours by nursing staff. She stated that call lights not being with reach could pose a risk for residents needs to not be met in a timely manner. This could lead to skin issues, feeling anxious, mad, and feeling of helplessness. She stated that last Inservice for all light was done two weeks ago. Record review of facility policy titled Call System, Residents updated 01/2025 read in part Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

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 (Resident # 51) of 6 reviewed for medication administration. The facility failed to ensure Licensed Staff signed the individual control drug record for Resident #51's after administering controlled medication on 09/02/2025 and 09/03/2025. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. The findings include: Resident # 51Review of Resident #51' s admission Record dated 09/04/2025 revealed [AGE] year-old male with an initial admission date of 02/14/2025 and readmission date of 07/05/2025. Review of Resident #51's Diagnoses dated 09/04/2025 revealed a diagnosis of insomnia (persistent problems falling asleep and staying asleep). Review of Resident #51 's 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Review of Resident #51 's Care Plan revised 08/21/2025 revealed resident was on sedative/ hypnotic therapy (Temazepam) related to insomnia. Review of Resident #51's Medication Administration Record (MAR) dated September 2025 revealed Temazepam Oral Capsule 7.5 MG (Temazepam) Give 1 capsule by mouth at bedtime for insomnia. Review of Resident #51's individual control drug record for medication Temazepam on 09/04/25 at 11:35 am revealed two missing nurse signatures on 09/02/2025 and 09/03/2025. An interview on 09/05/2025 at 1:30PM with the DON, revealed that nurses were trained to look at residents' orders, make sure it was the right medication for the right resident and administer medication, and sign the individual control drug record it as soon as the nurse was done administering medication. She stated that this was done to create a clear record of who administered the medication, when and to whom, allowing tracking of controlled medication. She stated that she did not know the risks of not signing the individual narcotic sheet. She stated that the ADON's and herself were responsible for ensuring that all narcotic records were adequately completed. She stated that the ADON's and herself completed random audits throughout the week to ensure they were filled out correctly. She stated that there had been an in-service to staff regarding this recently in August. In an interview on 09/05/2025 at 1:50 PM with RN J, she stated that the purpose of the individual narcotic record was to have a count of narcotic medications, to know that it was the right resident, right dose and to make sure that the correct medication of resident was being given. She stated that she was trained to look in the book, locate the individual narcotic record for the resident and to ensure the count matched the sheet before being given. Nurses were to sign and document as soon as the medication was pulled. She stated that signing the narcotic sheet was a form of acknowledging that the medication was given at the right time and the correct amount was given. She stated that narcotic sheets should be filled out in their entirety to avoid drug diversion. She stated that the facility did provide an in-service regarding this, she could not recall the date. An interview with the Administrator on 09/05/25 at 2:39 PM, revealed that the purpose of an individual narcotic sheet was to keep track of the narcotics being administered and to ensure that drug diversion was not happening. She stated that it kept track of the times they were given, and who was administering them. She stated that it was important for the nurses to sign the sheet when administering the medication, because if there was an issue with the medication, they knew what nurse last gave it. She stated that diversion of medications was the risk because it would not be known who had access to it last. She stated that she did not recall if an in-service was done regarding this. Record Review of the facility's policy titled Controlled Substances dated 01/2025 read in part When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage . Date and time of administration, amount administered and the signature of the nurse administering the dose.

Based on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for DON coverage. The facility failed to have a full-time DON as of 03/23/25. This failure could place residents at risk of lack or nursing oversight and a higher level of care. Findings include: Record review of staff hours Employee Timecard Report, from 03/16/25 through 03/31/25, indicated there was no DON in the facility from 03/20/25 through 03/31/25. On 04/01/25 there was no DON. Record review of the DON's Letter of Resignation, dated 03/23/25, revealed the DON submitted his letter of resignation on 03/23/25 to immediate resignation on 03/24/25. In an interview on 03/31/25 at 2:23 PM with the ADON, he stated they did not have a DON anymore. The ADON stated they had one when the state agency entered the facility on 03/22/25 and was out on a personal matter but later resigned. The ADON stated the last day the DON worked at the facility was on 03/23/25. The ADON stated since then they had been without a DON. In an interview on 03/31/25 at 3:09 PM with HR, she stated the facility did not have a full time DON nor an interim DON. HR stated the last day the DON was employed with the facility was on 03/23/25 which left the facility 8 days without a DON. In an interview on 03/31/25 at 4:11 PM with the Administrator, she stated the facility did not have a DON Coverage policy and followed state guidelines. In an interview on 03/31/25 at 4:16 PM with the Administrator, she stated the last time the facility had a full time DON was on 04/01/25. The Administrator thought about it and remarked she received the DON's letter of resignation on 03/23/25 and his last official day was on 03/24/25. The Administrator stated they had the ADON (who was an LVN), a PRN RN, and the Regional Clinical Support Specialist (who was also an LVN) to cover in the meantime. The Administrator stated the facility was supposed to have a DON to manage the nursing part of the building. The Administrator stated they were using indeed and Facebook to try to hire a DON . The Administrator stated the negative outcome of not having a full time DON in the facility was having issues with policies and regulations .

Based on observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care. The facility failed to ensure Resident #2's wound vac setting was set at 115mmhg as ordered by the physician. This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet dated 12/21/24 revealed a [AGE] year-old male with diagnoses of sepsis (life-threatening emergency that happens when your body's response to an infection damages vital organs and, often, causes death), pressure ulcer to sacrum, and hemiplegia (paralysis on one side of the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating his cognition was severely impaired and had pressure ulcers. Record review of Resident #2's physician order dated 2/11/25 revealed wound care to sacrum stage 4 pressure cleanse with Dakin's with normal saline pat dry apply wound vac with granulated foam secure with Tegaderm and set negative pressure continuously at 115mmhg every Monday, Wednesday, and Fridays. Record review of Resident #2's care plan dated 2/19/25 revealed a focus area for pressure ulcer stage 4 to sacrum with interventions that included administer treatments as ordered and monitor effectiveness. During an observation and interview on 2/19/25 at 11:23 am, Resident #2 was in bed facing the door with wedges under his right torso, he was alert and oriented to person and event. Resident #2 denied any concerns with his wound care and denied any discomfort. Resident #2's wound vac was set at 125mmhg . Resident #2 stated he did get wound care treatment and stated it was almost every day. During an observation and interview on 2/19/25 at 3:35 pm, Resident #2 was in bed facing the window with pillows under his left torso and denied any discomfort to wound. The DON stated Resident's wound vac was set at 125mmhg. The DON stated local supply store delivered the wound vac on 2/11/25 and set the rate settings. The DON stated it was expected for the nurses to check the wound vac during wound care to ensure the settings were as ordered. The DON stated she was the nurse who had provided wound care to Resident #2 in the morning (2/19/25) and did not check the wound vac settings. The DON stated the wound vac was supposed to be set at 115mmhg. The DON stated the risk included increased bleeding from suction . During an observation and interview on 2/20/25 at 9:30 am, Resident #2 denied and pain/discomfort to his wound. The ADON assisted him in repositioning to his right side to face the window. The wound vac dressing was slightly lifting on one edge and was dated 2/19/25. ADON noted less necrotic tissue, granulation present, minimal drainage, some slough around the area, and no signs of infection. During an interview on 2/20/25 at 3:16 pm, The Doctor stated that there were no concerns regarding Resident #2's sacral wound at that time. T The Doctor stated there had been no indication of increased drainage or infection. The Doctor stated that the nursing staff was expected to follow the treatment orders as written. The Doctor stated that for not setting the wound vac settings as ordered were increased drainage, discomfort, and pain. During interview on 2/20/25 at 4:46 pm, the Administrator stated she would refer the wound care treatment to the DON. Record review of the facility's policy Wound Treatment Management dated 07/2022 read in part wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing change . The facility did not have a policy specifically for the wound vac management.

Based on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #4) reviewed for indwelling catheter. The facility failed to ensure Resident #4's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection. Findings include: Record review of Resident # 4's face sheet, dated 11/27/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included urinary tract infection (a bacterial infection that affects the urinary tract, which includes the bladder, ureters, and kidneys) and retention of urine (a condition that occurs when a person is unable to empty their bladder completely). Record review of Resident # 4's quarterly MDS, dated [DATE], revealed an intact cognition BIMS score of 14 to be able to recall and make daily decisions. Resident #4 was diagnosed with Neurogenic Bladder (condition that occurs when the nerves and muscles in the bladder don't communicate properly with the brain, resulting in loss of bladder control) and retention of urine. Record review of Resident #4's care plan, dated 06/03/24, revealed indwelling catheter related to infection. Check tubing for kinks each shift. Monitor and document intake and output as per family policy. Resident #4 was coded for indwelling catheter. Record review of Resident #4's order recap, dated 06/02/24, revealed Foley catheter: Change drainage bag as needed for leaking/obstruction. Privacy Bag for urinary drainage bag at all times while in bed, while walking or in wheelchair every shift. Record review of Resident # 4's care plan, dated 06/02/24, revealed bladder incontinence with the presence of catheter: Indwelling. Assess resident for bowel and bladder training. Change catheter/drainage bag/tubing per MD orders. Ensure staff aware of correct placement of catheter gravity drainage bag and tubing. Keep tubing/bag below the bladder, do not kink tubing. Observation and interview on 11/19/24 at 10:13 AM, with Resident #4 revealed Resident #4 was on his bed lying down and watching television. A nurse's tray table was positioned towards Resident #4's left side. It was observed Resident #4's catheter bag was hanging off the left side touching the floor and the leg of the nurse's tray table. Resident #4 stated he did not notice his catheter bag was on the floor. Resident #4 stated it could have been when the nurse or CNA was in the room where they did not hang it on the side of the bed. Resident #4 stated he could not remember when the last time they had gone into the room. During an interview on 11/26/24 at 10:32 AM, LVN B stated catheter bags were to be hooked on the resident's bed with a privacy bag on it. LVN B stated the bags were hung so as not to pull on the resident's private parts which could hurt them or cause injury. LVN B stated the catheter bag was to be off the floor and not touching the floor. LVN B stated it was the nursing staff's responsibility to ensure the catheter bags like Resident #4's was off the floor and hung. LVN B stated the risk would be contamination and hygiene purposes. During an interview on 11/26/24 at 11:11 AM, , the DON stated residents who had catheter bags were to have them hooked on the side of the residents' bed. The DON stated the catheter bags were not to be on the floor due to the risk of infection. The DON stated Resident #4's catheter bag should have been hung and not on the floor. The DON stated everyone was responsible for ensuring the catheter bag(s) were hung on the bed or the wheelchair depending on where the resident was at. During an interview on 11/26/24 at 10:16 AM, CNA A stated residents were to have the catheter bags next to the resident. CNA A stated when the resident was in the wheelchair then it would be hung underneath. CNA A stated if the resident was on the bed, then it would be hung on the side of the bed. CNA A stated the catheter bag could not be on the floor due to contamination. Record review of the facility's Indwelling Catheter Use and Removal, dated 07/20, revealed Policy: It was the policy of the facility to ensure that indwelling urinary catheters that are inserted or remain in place area justified or removed according to regulations and current standards of practice . The use of indwelling catheters increase the risk of urinary tract infections. If an indwelling catheter was in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Record review of the facility's Infection Prevention and Control Program policy, dated 03/2022, revealed The facility has established and maintains an infection prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in four of four halls reviewed for environmental conditions. -The facility failed to clean facility over the weekend of 07/28/24 due to not having sufficient personal to clean the resident rooms and common areas. -The facility failed to maintain the environment free of accident hazards. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment. Findings included: Hall 100: In an observation on 07/29/24 at 6:30 AM, revealed tile floors by the entrance of the facility and resident halls were full of dust, dried black stains, and paper particles. There was a white tablet on the floor by the decentralized nurse's station in the 300 Hall. Observation on 07/29/24 at 7:26 AM, in room [ROOM NUMBER] revealed, floor was covered with food particles .There was toothette oral swab under the side of Bed B. In an observation and interview on 07/29/24 at 7:45 AM, with Med Aide E, revealed sharp container on the side of medication cart in Hall 100 was full. There was a blue glove above the black marker on the sharps container that indicate the container was full. Med Aide E said, she did not know who was responsible for checking if the sharps containers needed to be replaced. In an observation on 07/29/24 at 7:34 AM, revealed there was a white sheet on the floor soaked with water and caution sign directly in front of Janitor's Closet. In an observation on 07/29/24 at 8:05 AM, revealed water was leaking from the condensation pipe in the Mechanical Room, the drain was full of water and water was leaking into the hallway and Janitor Room next to the Mechanical Room. In an observation on 07/29/24 at 8:05 AM, revealed water was leaking through the floor base into the Janitor room from the Mechanical Room. It was observed the floor was full of dust and a piece of paper and piece of clear plastic were on the floor. In an observation and interview on 07/29/24 at 8:10 AM, with Maintenance Supervisor revealed, the flapper in the drain in the mechanical room was rusted, the edges were cracked, edges were missing on half of the flapper seal, round tube connected to the flapper was cracked. The maintenance Director said, If no water was dripping from the condensation pipe, the flapper dried and would get stuck on the drain and will not allow the water to drain into the drain. That why the water was overflowing to the floor, was leaking into the wall of the Janitor's room and into the hallway. He said no one had had called him to report water was leaking to the hallway from the Mechanical Room. He said he checked the drain once a week and had not noted any problems with the drain. Observation on 07/29/24 at 10:00 AM, revealed Central Supply Clerk K, was replacing the sharp container in the Hall 100. In an interview on 08/02/24 at 12:37 PM, with the Administrator, revealed, the facility was short two housekeepers on the weekend on 07/27/24 and 07/28/24. Administrator stated, It was a perfect storm, that is why the facility was not cleaned on the weekend. Hall 200: In an observation at 8:39 AM, revealed housekeeper had mopped 3/4 of one side of the hallway and placed caution signs. In an observation and interview on 07/29/24 at 8:43 AM, revealed Social Worker had disregarded the Caution Signs, and was observed walking on the wet floor towards the resident rooms. The Social Worker said she was going to get residents from their rooms to take them to the dining room. In an observation and interview on 07/29/24 at 8:58 AM, with Housekeeper Q revealed she had been trained to mopped 3/4 and to place two caution signs to alert the residents and staff that the floor was wet. Observation on 07/29/24 at 8:58 revealed that Housekeeper T was mopping the floor on the side of the nurse's station by the director of nurse's office and only had one caution sign, alerting others that the floor was wet. The housekeeper said they had been trained to mop a small area of the floor and to place two caution signs until the floor was dry. She said she only found one caution sign and that is why she had placed her housekeeping card on the other end, to block the area and keep people from walking on the floor. Observation on 07/29/24 at 7:58 AM, in the 200 Hall revealed was a dead cricket was on the floor in the hallway. Observation on 07/29/24 at 9:05 AM revealed in the 400 hall there was a white tablet on the floor. The surveyor confirmed the findings with LVN D who was assigned to work on the 300 Hall. Laundry Room: Observation and interview on 08/01/24 at 3:43 PM, with Housekeeper P revealed, the chemical dispensers connected to the washing machines was squirting solution on the walls and floors. There were dried white stains on the walls and on the floor by the washing machines. The Hand sink had white calcium buildup around the edges of the sink and there were light gray stains in the sink around the drain. Oxygen Storage Room: Observation and interview on 08/02/24 at 8:38 AM, with central supply clerk K revealed oxygen tanks were stored in storage racks. The floor was full of dust, paper particles, hair, and plastic seals. He said he had not noticed that oxygen needed to be cleaned.

FACILITY Environment Observation on 07/29/24 at 6:30 AM, revealed tile floors by the entrance of the facility and resident halls were full of dust, dried black stains, and paper particles. There was a white tablet on the floor by the decentralized nurse's station in the 300 Hall. Observation on 07/29/24 at 7:34 AM, revealed there was a white sheet on the floor soaked with water and caution sign directly in front of Janitor's Closet. Observation on 07/29/24 at 8:05 AM, revealed water was leaking from the condensation pipe in the Mechanical Room, the drain was full of water and water was leaking into the hallway and Janitor Room next to the Mechanical Room. Observation on 07/29/24 at 8:05 AM, revealed water was leaking through the floor base into the Janitor room from the Mechanical Room. It was observed the the floor was full of dust and a piece of paper and plastic were on the floor. Observation and interview on 07/29/24 at 8:10 AM, revealed with Maintenance Supervisor, revealed the flapper rusted, and the edges were cracked and edges were missing on half of the flapper seal, round tube connected to the flapper was cracked. The maintenance Director stated, If no water is dripping from the condensation pipe, the flapper dries and will get stuck on the drain and will not allow the water to drain into the drain. That why the water was over flowing to the floor and was leaking into the wall of the Janitor's room and to the hallway. Maintenance Supervisor reported that on had called him to report that water was leaking to the hallway from the Mechanical Room. Maintenance Supervisor reported that he checked the drain once a week. Observation at 8:39 AM, revealed that housekeeper had mopped 3/4 of one side of the hallway and placed caution signs. Housekeeper stated, that is how she had been trained to mop 3/4 of one side of the hallway and placed caution signs. Observation and interview on 07/29/24 at 8:43 AM, revealed revealed that housekeeper had mopped 3/4 of the floor on the 200 Hall. It was observed that the Social Social Worker disregarded the Caution Sign, and was observed walking on the wet floor towards the resident rooms. The Social Worker stated, she was going to get residents from their rooms to take them to the dining room. Observation on 07/29/24 at 8:58 revealed that [NAME] housekeeper was mopping the floor on the side of the nurses station by the director of nurses office and only had one caution sign, alerting others that the floor was wet. The housekeeper reported they had been trained to mop a small area of the floor and to place two caution signs Until the floor was dry. The housekeeper stated that since she only had one caution sign in her housekeeping card she had placed her housekeeping card on the other end to block the area and keep people from walking on the floor because she did not have another caution sign to place. Observation on 07/29/24 at 7:58 AM, in the 200 Hall revealed a dead cricket was on the floor in the hallway. Observation on 07/29/24 at 9:05 AM revealed that in the 400 hall there was a white tablet on the floor. The surveyor confirmed the findings with [NAME] LVN assigned to work on the 400 Hall.

Based on interview and record review the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: CNA B failed to follow Resident #1's comprehensive person-centered care plan to use a hoyer lift when transferring Resident #1 and instead used a one-person transfer (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely). This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Record review of Resident #1's face sheet, dated 11/07/23, revealed admission on 10/18/23 to the facility. Record review of Resident #1's history and physical, from the hospital, dated 08/11/23, revealed a [AGE] year-old female, diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), deep vein thrombosis (DVT) (a medical condition that occurs when a blood clot forms in a deep vein), and muscle weakness (lack of muscle strength). Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS (a quick snapshot of how well you are functioning cognitively) indicating moderate cognitive impairment score of 7. Activities of daily living for sit to lying down requires a substantial/maximum assistance from staff. Resident #1 was diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), arthritis (joint inflammation), and idiopathic neuropathy (Neuropathy is when nerve damage interferes with the functioning of the peripheral nervous system. When the cause can't be determined). Record review of Resident #1's care plan, dated 10/18/23, revealed activities of daily living self-care performance for transfers required two-person assistance, with hoyer lift. Record review of Resident #1's progress notes from LVN A, dated 10/22/23, This nurse was notified by CNA B that Resident #1 presented with skin tear to right calf area. This nurse walked into Resident #1's room and noted a moderate amount of blood on floor and on Resident #1's leg. This nurse assessed the area and noted a laceration to Resident #1's right calf, measuring 5x3 centimeters. Adipose tissue (body fat) was visible with moderate bleeding. Resident #1 denied pain or discomfort at that time. Resident #1 refused pain medications. Resident #1's pedal (a pulse obtained from the top of the foot, used to assess circulation to the lower extremities) was faint, Resident #1's leg was cold, distally. Resident #1 had active range of motion to right lower extremity. Emergency Medical Services called, medical doctor notified to transfer to hospital, responsible party, ADON, DON, and Administrator notified of laceration to lower leg. During an interview, on 11/07/23 at 9:16 AM, Resident #1 stated the nursing staff use the hoyer lift to transfer her from her bed to her wheelchair and back from her wheelchair to her bed anytime she goes out of bed and into bed. Resident #1 stated CNA B physically picked her up from the wheelchair. Resident #1 stated she told CNA B to use the hoyer lift to transfer her. Resident #1 stated CNA B told her he was strong enough to pick her up, without the hoyer lift. Resident #1 stated CNA B physically picked her up, by himself, without assistance from any other staff or the Hoyer lift. Resident #1 stated when CNA B physically picker her up, she hit the bed bar, which caused a laceration to her leg. During an interview on 11/07/23 at 11:07 AM, ADON stated there was a risk if nursing staff were trained improperly or did an improper transfer on a resident. The ADON stated the risk could be that they hurt themselves and or the resident. The ADON stated CNA B had said he did a one person transfer for Resident #1 instead of a hoyer lift transfer. The ADON stated the one-person transfer used by CNA B on Resident #1 was an improper transfer. The ADON stated there was a risk for doing the transfer improperly on Resident #1, like the injury she got of the laceration on her right lower leg. During an interview on 11/07/23 at 11:40 AM, CNA C stated she was in-serviced a week or two weeks ago on residents that use a hoyer lift which cannot be transferred with a one-person transfer. CNA C stated nursing staff doing a one person transfer on a resident who was hoyer lift transfer would be inappropriate not being the correct transfer and should not be attempted without the hoyer lift. During an interview on 11/07/23 at 1:31 PM, CNA D stated physical therapy had given the nursing staff an in-service a week or so ago on transfers and hoyer lifts. CNA D stated the nursing staff were told that it was required to have two people to do a hoyer lift. CNA D stated if a resident was a hoyer lift and was transferred using a one person transfer then that would be a wrong transfer. CNA D stated the risk would be the resident could have a fall and the nursing staff could hurt themselves. During an interview on 11/07/23 at 2:00 PM, LVN A stated CNA B told her that he had transferred Resident #1 from the wheelchair to the bed. LVN A stated that CNA B was alone with no other nursing staff in the room when she walked in. LVN A stated Resident #1 required a hoyer lift for transfer and she did not see the hoyer in the room. LVN A stated she did not get a chance to ask CNA B why he did not use a hoyer lift to conduct the transfer. LVN A stated the transfer of a one person on Resident #1 used by CNA B was an improper transfer. During an interview on 11/07/23 2:56 PM, CNA B stated he told CNA E to go a use the hoyer and he would go and lay down Resident #1. CNA B stated he knew Resident #1 required a hoyer lift for transfers. CNA B stated he grabbed Resident #1 and sat her down on the bed. CNA B stated he felt something running down Resident #1's leg and though it was possible urine from the brief. CNA B stated he thinks the laceration came from the wheelchair because as he was lifting Resident #1 she had moved her right leg back near the footrest getting it hooked when he moved her to the bed. During an interview on 11/07/23 at 3:15 PM, CNA E stated she had received training on transfers and hoyer upon hire. CNA E stated if a resident required a hoyer lift for transfers a nursing staff member may not use a one person transfer to transfer the resident. CNA E stated there would be a risk because you need two people for a hoyer transfer and do not want risk the resident having a fall. During an interview on 11/07/23 at 4:04 PM, CNA K stated if a resident was a two person transfer that it could not be done with a one-person transfer. CNA K stated there was a risk of not following the residents approved transfer in that anything could happen to the resident if the correct transfer was not happened by the nursing staff. During an interview on 11/07/23 at 4:28 PM, CNA L stated to operate the hoyer lift it required two people. CNA L stated if nursing staff needed help to go and ask for help. CNA L stated there was a risk to the resident if an improper transfer was conducted. CNA L stated the risk could have been a fracture or fall. During an interview on 11/07/23 at 4:30 PM, CNA M stated when operating a hoyer lift there should be two people when transferring a resident. CNA M stated if the resident was a hoyer lift you could not use a one person transfer on that resident. CNA M stated this was because you could hurt the resident or yourself. During an interview on 11/07/23 at 4:32 PM, CNA N stated that if the resident was a hoyer lift it would require two nursing staff to transfer the resident. CNA N stated this was because of security and making sure the resident was safe. CNA N stated doing the transfer incorrectly could be a risk of a fall. During an interview on 11/08/23 at 8:35 AM, CNA O stated she did receive an in-service a couple of week ago regarding using two people to transfer when using a hoyer lift. CNA O stated if the transfer of a resident required a hoyer lift transfer then the nursing staff could not use any other transfer. CNA O stated not following the approved transfer of the resident could be risk for a fall, injury, or the staff getting hurt. During an interview on 11/08/23 at 8:46 AM, CNA P stated when using a hoyer it was required to use two people not one person when transferring a resident that was a hoyer lift. CNA P stated if the resident was a hoyer lift you could not transfer them using the one person transfer as it could be a risk to the resident. CNA P stated the risk could be the resident falling, the residents' legs could get damaged, a lot of things could happen. During an interview on 11/09/23 at 10:27 AM, CNA F stated there had to be two people to transfer a resident that required the use of a hoyer lift for transfer. CNA F stated the nursing staff had received training on following care plans. CNA F stated the way the care plan was written in the facility system was the way the nursing staff had to follow them. CNA F stated there could be a risk of not following the care plan of a resident. CNA F stated the risk could be injury to the resident or to the nursing staff. During an interview on 11/09/23 at 10:40 AM, Director of Therapy stated she was part of the meeting for the in-services given for the incident. Director of Therapy stated the in-service consisted of one-to-one transfer, two person transfers, and hoyer lift transfer and how to conduct them properly with residents. Director of Therapy stated they told nursing staff if they felt unsafe to come and get them to assist with education and training. Director of Therapy stated there could be a risk of doing the transfer incorrectly. Director of Therapy stated the risk was hurting the resident or yourself. Director of Therapy stated CNA B was trained by her on conducting transfer and hoyer lift transfers in which he was in-serviced. Director of Therapy stated nursing staff were also in-service on care plans and where to look for them. Director of Therapy stated there was a risk of not following the care plans. Director of Therapy stated the risk would be a resident having an injury like the incident with Resident #1, in which CNA B did not follow the hoyer lift transfer and did a one-person transfer resulting in injury. During an interview on 11/09/23 at 11:22 AM, CNA G stated she was in-serviced on following care plans. CNA G stated they were given information about the plans for the residents and hoyer lifts and transfers. CNA G stated nursing staff were told to make sure they were giving the correct services when attending to the resident. CNA G stated she had seen her supervisors doing monitoring checks on the nursing staff to ensure they were doing the transfers correctly on residents. CNA G stated not following the care plan could result in injury to both the resident and staff. During an interview on 11/09/23 at 11:40 AM, MDS Coordinator stated Resident #1 required a two-persons assistance for transfer. MDS Coordinator stated Resident #1 was being transferred when she had obtained skin tear to her leg that . MDS Coordinator stated the risk could be an injury to the resident. MDS Coordinator stated they received in-services on following care plans and an in-service on neglect in response to the incident with Resident #1. During an interview on 11/09/23 at 12:00 PM, CNA H stated she had received an in-service on care plans. CNA H stated nursing staff must follow what was on the care plan. CNA H stated the risk of not following the care plan could be neglect and or an accident to the resident. CNA H stated residents who are hoyer lift need to have two people in order to transfer the resident and cannot be a one-person transfer. During an interview on 11/09/23 at 12:10 PM, CNA I stated if a resident required assistance of a two persons for transfer then it was always required the use of two person for the transfer until told otherwise. CNA I stated if a resident a hoyer lift and the nursing staff conducted a one person transfer then it would not have been a correct transfer. CNA I stated you could not do that transfer because it could cause the resident or nursing staff to get hurt. CNA I stated she had received an in-service training recently on following care plans. CNA I stated the purpose of a care plan was to give the resident the right care that they needed. CNA I stated there could be a risk of not following the care plan. CNA I stated if the care plan had a resident requiring a hoyer lift and giving them a one person transfer could result in dropping the resident or hurting them. Record review of the facility comprehensive care plans policy dated 02/2023 revealed, It was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe - - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 4 residents reviewed for accidents. The facility failed to ensure CNA B used the hoyer lift to transfer Resident #1 knowing Resident #1 required the use of a hoyer lift for transfers, instead using the one person transfer technique (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely) to prevent injury. This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who required the use of a hoyer lift for transfers, by placing them at risk of improper transfers resulting in injury. Findings include: Record review of Resident #1's face sheet dated 11/07/23 revealed admission on 10/18/23 to the facility. Record review of Resident #1's history and physical, from the hospital, dated 08/11/23, revealed a [AGE] year-old female, diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), deep vein thrombosis (DVT) (a medical condition that occurs when a blood clot forms in a deep vein), and muscle weakness (lack of muscle strength). Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS (a quick snapshot of how well you are functioning cognitively) indicating moderate cognitive impairment score of 7. Activities of daily living for sit to lying down requires a substantial/maximum assistance from staff. Resident #1 was diagnosed with osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), arthritis (joint inflammation), and idiopathic neuropathy (Neuropathy is when nerve damage interferes with the functioning of the peripheral nervous system. When the cause can't be determined). Record review of Resident #1's care plan, dated 10/18/23, revealed activities of daily living self-care performance for transfers required two-person assistance, with hoyer lift. Record review of Resident #1's progress notes from LVN A dated 10/22/23, This nurse was notified by CNA B that Resident #1 presented with skin tear to right calf area. This nurse walked into Resident #1's room and noted a moderate amount of blood on floor and on Resident #1's leg. This nurse assessed the area and noted a laceration to Resident #1's right calf, measuring 5x3 centimeters. Adipose tissue (body fat) was visible with moderate bleeding. Resident #1 denied pain or discomfort at that time. Resident #1 refused pain medications. Resident #1's pedal pulse (a pulse obtained from the top of the foot, used to assess circulation to the lower extremities) was faint, Resident #1's leg was cold, distally. Resident #1 had active range of motion to right lower extremity. Emergency Medical Services called, medical doctor notified to transfer to hospital, responsible party, ADON, DON, and Administrator notified of laceration to lower leg. During an interview, on 11/07/23 at 9:16 AM, Resident #1 stated the nursing staff use the hoyer lift to transfer her from her bed to her wheelchair and back from her wheelchair to her bed anytime she goes out of bed and into bed. Resident #1 stated CNA B physically picked her up from the wheelchair. Resident #1 stated she told CNA B to use the hoyer lift to transfer her. Resident #1 stated CNA B told her he was strong enough to pick her up, without the hoyer lift. Resident #1 stated CNA B physically picked her up, by himself, without assistance from any other staff or the Hoyer lift. Resident #1 stated when CNA B physically picker her up, she hit the bed bar, which caused a laceration to her leg. Observation, on 11/07/23 at 9:24 AM, with the Regional Nurse, revealed no sharp areas were identified to Resident #1's metal framed bed, visually or by physical touch. Observation of Resident #1's room revealed her furniture was in good condition and no hazards were identified, that may have caused the laceration. Observation, on 11/07/23 at 2:24 PM, with Resident #1, revealed no defects or sharp areas were noted to her wheelchair. During an interview, on 11/07/23 at 11:07 AM, the ADON stated all nursing staff are trained on transfers and hoyer lifts. The ADON stated the therapy department trains the nursing staff on transfers and hoyer lifts. The ADON stated the therapy department informed the nursing staff to notify the therapy department if they needed additional training. The ADON stated CNA B said he did a one person transfer for Resident #1 instead of a hoyer lift transfer. The ADON stated the one-person transfer used by CNA B on Resident #1 was an improper transfer. The ADON stated there was a risk for injury to the resident if they utilize improper technique for resident transfers. The ADON stated CNA B was suspended pending the investigation, was given in-service on transfers after the incident happened. The ADON stated they were trained on abuse, neglect, and exploitation upon hire and as needed. During an interview, on 11/07/23 at 11:40 AM, CNA C stated she was trained on transfers and hoyer lifts, from the therapy department. CNA C stated the therapy department instructed the nursing staff to use the gait belts when transferring residents. CNA C stated she was in-serviced a week or two weeks ago on residents that require a hoyer lift, stating they cannot be transferred with a one-person transfer. CNA C stated nursing staff doing a one person transfer on a resident who requires a hoyer lift for transfers would be inappropriate and should not be attempted without the hoyer lift. CNA C stated she was trained on abuse, neglect, an exploitation and received an in-service a week or two ago. During an interview and observation, on 11/07/23 at 1:05 PM, with the Regional Nurse, she stated CNA B had no sharp object when transferring Resident #1. Regional Nurse stated she assessed Resident #1 and her bed and believed the laceration was related to her delicate skin, which could have been susceptible to injury. The Regional Nurse stated Resident #1 and CNA B had both stated the injury had come from the bed. During an interview, on 11/07/23 at 1:31 PM, CNA D stated she was trained on transfer and hoyer lifts, by the physical therapy department a week or so. CNA D stated the nursing staff were told it was required to have two people to do a proper transfer, utilizing the hoyer lift. CNA D stated if a resident required a hoyer lift for transfers and was transferred using a one person transfer that would not be a correct transfer. CNA D stated the risk would be the resident could have a fall and the nursing staff could hurt themselves. CNA D stated she was trained on abuse, neglect, and exploitation upon hire, as needed, and a week ago when she got in-serviced on transfers. During an interview, on 11/07/23 at 2:00 PM, LVN A stated she was notified by CNA B that Resident #1 was bleeding. LVN A stated she assessed Resident #1, who was laying on her bed and noted a laceration on her right lower leg. LVN A stated CNA B told her that he had transferred Resident #1 from the wheelchair to the bed. LVN A stated that CNA B was alone with no other nursing staff in the room when she walked in. LVN A stated Resident #1 required a hoyer lift for transfers and she did not see the hoyer lift in the room. LVN A stated Resident #1 told her she did not know how she got the laceration on her right leg. LVN A stated CNA B stated it might have been from the wheelchair. LVN A stated she checked the wheelchair and did not note any blood on the room floor, in front of the wheelchair. LVN A stated she did not get a chance to ask CNA B why he did not use a hoyer lift to conduct the transfer. LVN A stated the transfer of a one person on Resident #1 used by CNA B was an improper transfer, which put her at risk for injury. LVN A stated she had been trained on abuse, neglect, and exploitation upon hire, quarterly, and as needed. During an interview on 11/07/23 2:56 PM, CNA B stated the residents were coming back from dinner when Resident #1 wanted to lay down in her bed. CNA B stated the facility only had one hoyer lift and the battery was running low. CNA B stated there was only one hoyer and one battery for three hallways to use. CNA B stated that the facility did not have any other batteries to replace them with. CNA B stated he told CNA E to go and use the hoyer and he would go and lay down Resident #1. CNA B stated he knew Resident #1 required a hoyer lift for transfers. CNA B stated he grabbed Resident #1 and sat her down on the bed. CNA B stated he felt something running down Resident #1 leg and though it was possible urine from the brief. CNA B stated he thinks the laceration came from the wheelchair because as he was lifting Resident #1, she had moved her right leg back near the footrest getting it hooked when he moved her to the bed. CNA B stated he let LVN A know Resident #1 had a laceration to her right leg. CNA B stated he had received training in his other job doing home health on transfers and hoyer lifts. CNA B stated this was not the first time he had done a one person transfer on a resident that required the use of a hoyer lift because there were not enough hoyer lifts and batteries. CNA B stated he had not received training from the facility with transfers and hoyer lifts. During an interview on 11/07/23 at 3:15 PM, CNA E stated she had received training on transfers and hoyer upon hire. CNA E stated if a resident required the use of a hoyer lift for transfers a nursing staff member may not use a one person transfer to transfer the resident. CNA E stated there would be a risk because you need two people for a hoyer transfer and do not want risk the resident having a fall. During an interview on 11/07/23 at 4:04 PM, CNA K stated nursing staff had recently received an in-service on hoyer lift transfers. CNA K stated if the nursing staff felt they had questions or needed assistance to go talk to the therapy department. CNA K stated if a resident was a two person transfer that it could not be done with a one-person transfer. CNA L stated nursing staff were instructed to go ask for help if they needed it. CNA K stated there was a risk of not following the residents approved transfer in that anything could happen to the resident if the correct transfer was not happened by the nursing staff. During an interview on 11/07/23 at 4:28 PM, CNA L stated she was trained on transfers and hoyer lift transfers by the therapy department. CNA L stated to operate the hoyer lift it required two people. CNA L stated if nursing staff needed help to go and ask for help. CNA L stated there was a risk to the resident if an improper transfer was conducted. CNA L stated the risk could have been a fracture or fall. Observation on 11/07/23 at 4:29 PM, CNA K and CNA L used the hoyer lift to transfer Resident #2 from wheelchair to bed, transfer did not yield any concerns. During an interview on 11/07/23 at 4:30 PM, CNA M stated she was trained on transfers and hoyer lift transfers and had received an in-service on hoyer lift transfers. CNA M stated the nursing staff was shown how to transfer a resident from the wheelchair to the bed and bed to the wheelchair. CNA M stated when operating a hoyer lift there should be two people when transferring a resident. CNA M stated if the resident was a hoyer lift you could not use a one person transfer on that resident. CNA M stated this was because you could hurt the resident or yourself. During an interview on 11/07/23 at 4:32 PM, CNA N stated she had received training on transfers and hoyer lift transfers. CNA N stated that if the resident was a hoyer lift it would require two nursing staff to transfer the resident. CNA N stated this was because of security and making sure the resident was safe. CNA N stated doing the transfer incorrectly could be a risk of a fall. During an interview on 11/07/23 at 4:44 PM, the Regional Nurse stated any nursing staff that are PRN and nursing staff that missed the meeting (in-servicing on Abuse/Neglect, Exploitation, following care plans, and transfer/Hoyer lifts) were to be in-serviced when they came into work. During an interview on 11/08/23 at 8:35 AM, CNA O stated the nursing staff and received training on transfers and hoyer lift transfer. CNA O stated if a resident was new to the facility, they are not allowed to transfer the resident until therapy assess the resident and the nursing staff get educated on the resident's transfer. CNA O stated she did receive an in-service a couple of week ago regarding using two people to transfer when using a hoyer lift. CNA O stated if the transfer of a resident required a hoyer lift transfer then the nursing staff could not use any other transfer. CNA O stated not following the approved transfer of the resident could be risk for a fall, injury, or the staff getting hurt. During an interview on 11/08/23 at 8:46 AM, CNA P stated she was trained on transfer and hoyer lift transfers. CNA P stated to use two people not one person when transferring a resident that was aa hoyer lift. CNA P stated if the resident was a hoyer lift you could not transfer them using the one person transfer as it could be a risk to the resident. CNA P stated the risk could be the resident falling, the residents' legs could get damaged, a lot of things could happen. Observation on 11/08/23 at 9:29 AM with CNA F and CNA O, Resident #3 was transferred from wheelchair to bed using a hoyer lift. There where no concerns noted with the transfer. During an interview on 11/09/23 at 10:27 AM, CNA F stated the facility had given the nursing staff an in-service a couple of weeks ago on transfer/hoyer lifts. CNA F stated there had to be two people to transfer a resident that required the use of a hoyer lift to transfer. CNA F stated if a new resident was admitted to the facility, they are not allowed to transfer them until the therapy department assesses the resident and are told and shown the appropriate transfer for that the resident. CNA F stated during the in-service they were also told if they had any questions regarding the transfer of the resident that they may go and speak with the therapy department. CNA F stated the nursing staff had received training on following care plans. CNA F stated the way the care plan was written in the facility system was the way the nursing staff had to follow them. CNA F stated there could be a risk of not following the care plan of a resident. CNA F stated the risk could be injury to the resident or to the nursing staff. CNA F stated the facility supervisors are monitoring them on transfer randomly. CNA F stated if the monitors see something wrong, they are told immediately and corrected. During an interview on 11/09/23 at 10:00 AM, Regional Nurse stated the ADON, herself, and the therapy department do random rounds in the facility to ensure that transfers are being done correctly on the residents of the facility. The Regional Nurse stated if they see an issue with a transfer then they correct it right there and then with in-service. During an interview on 11/09/23 at 10:40 AM, Director of Therapy stated she was part of the meeting for the in-services given for the incident. Director of Therapy stated the in-service consisted of one-to-one transfer, two person transfers, and hoyer lift transfer and how to conduct them properly with residents. Director of Therapy stated they told nursing staff if they felt unsafe to come and get them to assist with education and training. Director of Therapy stated her therapy department does go conduct monitoring rounds randomly on nursing staff to ensure they are doing the transfer correctly. Director of Therapy stated if something was seen incorrectly that the nursing staff will be corrected on body mechanics and educate them on safer techniques. Director of Therapy stated there could be a risk of doing the transfer incorrectly. Director of Therapy stated the risk was hurting the resident or yourself. Director of Therapy stated CNA B was trained by her on conducting transfer and hoyer lift transfers in which he was in-serviced. Director of Therapy stated nursing staff were also in-service on care plans and where to look for them. Director of Therapy stated there was a risk of not following the care plans. Director of Therapy stated the risk would be a resident having an injury like the incident with Resident #1, in which CNA B did not follow the hoyer lift transfer and did a one-person transfer resulting in injury. During an interview on 11/09/23 at 11:22 AM, CNA G stated she was in-serviced on following care plans. CNA G stated they were given information about the care plans for the residents and hoyer lifts and transfers. CNA G stated nursing staff were told to make sure they were giving the correct services when attending to the resident. CNA G stated she had seen her supervisors doing monitoring checks on the nursing staff to ensure they were doing the transfers correctly on residents. CNA G stated not following the care plan could result in injury to both the resident and staff. During an interview on 11/09/23 at 11:40 AM, MDS Coordinator stated Resident #1 required two-persons assistance for transfer. MDS Coordinator stated Resident #1 was being transferred when she obtained a skin tear to her leg. MDS Coordinator stated if the nursing staff knew that the resident required the use of a hoyer lift for transfers, requiring two people and still conducted a one person transfer then that nursing staff would be neglectful. MDS Coordinator stated the risk could be an injury to the resident. MDS Coordinator stated nursing staff are trained on transfers and hoyer lifts by the therapy department. MDS Coordinator stated staff are trained on abuse, neglect, and exploitation upon hire and as needed. MDS Coordinator stated they received in-services on following care plans and an in-service on neglect in response to the incident with Resident #1. During an interview on 11/09/23 at 12:00 PM, CNA H stated she had received an in-service on care plans. CNA H stated nursing staff must follow what was on the care plan. CNA H stated the risk of not following the care plan could be neglect and or an accident to the resident. CNA H stated it was said that when the facility receives a new admission that the nursing staff are not allowed to transfer the resident until the therapy department assesses the resident and educates the nursing staff on the resident's transfer. CNA H stated residents who are hoyer lift need to have two people in order to transfer the resident and cannot be a one-person transfer. CNA H stated the nursing staff also received an in-service on abuse, neglect, and exploitation. During an interview on 11/09/23 at 12:10 PM, CNA I stated she had received training on transfers a couple of weeks ago. CNA I stated the nursing staff was instructed on how to transfer resident by the therapy department and to let the nurses or therapy department know if they needed help or had questions regarding the residents transfer. CNA I stated if a resident required assistance of two persons for transfer then it was always a two person transfer until told otherwise. CNA I stated if a resident required the use of a hoyer lift and the nursing staff conducted a one person transfer then it would not have been a correct transfer. CNA I stated you could do that transfer because it could cause the resident or nursing staff to get hurt. CNA I stated she had received an in-service training recently on following care plans. CNA I stated the purpose of a care plan was to give the resident the right care that they needed CNA I stated if the care plan had a resident requiring a hoyer lift and giving them a one person transfer could result in dropping the resident or hurting them. CNA I stated she had received an in-service on abuse, neglect, and exploitation upon hire and recently a couple of weeks ago. CNA I stated it would be considered neglectful if the staff knew the resident was a two person hoyer lift transfer and they still transferred the resident using the one person transfer. CNA I stated yes there would be a risk to the resident because there was a reason why they were a hoyer lift transfer. During an interview on 11/09/23 at 12:27 PM, Regional Nurses stated CNA B was not neglectful with Resident #1 in regard to the transfer. The Regional Nurse stated she does not believe CNA B had bad intensions and was remorseful. The Regional Nurse stated she does not believe CNA B did the transfer wrong to deliberately to hurt Resident #1. Record review of the facility safe resident handling/transfer policy not dated revealed it was the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. - Two staff members must be utilized when transferring residents with a mechanical lift. - Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. - Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. - Resident lifting and transferring will be performed according to the resident's individual plan of care. - Staff will perform mechanical lifts/transfers according to the manufacture's instructions for use of the device. Record review of facility hoyer lift manual not dated revealed, the intended use of this lifting device was for the safe lifting and transfer of an individual form one resting surface to another (such as bed to a wheelchair). Lifts may require two people to safely operate the lift. Record review of facility abuse, neglect, and exploitation policy not dated revealed it was the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. - Neglect - failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Identification of neglect - failure to provide care needs such as comfort, safety, turning, and positioning. Record review of the facility in-service training report for Following care plan/Kardex for proper transfers dated 10/22/23 revealed staff must follow policy, care plan, Kardex when transferring residents. Record review of the facility in-service training report for Abuse, Neglect, and Exploitation dated 10/22/23 revealed policy on Abuse, Neglect, and Exploitation. Record review of the facility in-service training report for Max assist (when the assisting person(s) or device(s) are required to perform approximately 75 percent of the work of a mobility task while you perform 25 percent of the work) transfer training/hoyer lift mechanics dated 10/27/23 revealed training focused on proper and safe transfer training with a max assist person and use of hoyer lift. Record review of CNA B's in-service training report for proper resident transfer procedures for safe resident care not dated was provided by Regional Nurse as in-service for the incident revealed the policy of safe resident handling/transfers with CNA B's signature. Record review of CNA B's training/in-service upon hire of Reporting abuse/neglect dated 05/03/23 revealed CNA B's signature of competency (the quality or state of having sufficient knowledge, judgment, skill, or strength) for the abuse/neglect training. Record review of CNA B's training/in-service received training in fall risk/transfers dated 09/28/23 revealed Fall risk/transfer training giving by Director of Therapy with CNA B's signature of competency ((the quality or state of having sufficient knowledge, judgment, skill, or strength) for the fall risk/transfer training.