Every finding on record at Ayers Health and Rehabilitation Center

Based on observation, interview, and record review the facility failed to provide an accurate assessment for 3 (Resident #22, #44, and #109) of 7 residents reviewed for respiratory services.Findings include:1)Review of Resident #22's physician ordered dated 4/12/2026 read, Oxygen: Administer Oxygen @ (at) _3_L [liters] via nasal cannula, face mask, CONTINUOUS.Review of Resident #22's Minimum Data Set (MDS) titled Quarterly dated 6/13/2026 Section O Special Treatments, Procedures, and Programs did not document the use of oxygen.Review of Resident #22's Weights and Vitals Summary documented on 6/13/2026 at 01:05 oxygen saturation was 93 % (Oxygen Via Nasal Cannula), 6/12/2026 at 19:39 oxygen saturation was 93% (Oxygen via Nasal Cannula) through 6/7/2026 at 02:30 oxygen saturation was 98% (Oxygen via nasal Cannula).During an interview on 7/9/2026 at 9:43 AM with the MDS Coordinator stated, That one [assessment] was done by the MDS consultant. Most of them are oxygen saturation documented using oxygen via nasal cannula. It needs to be coded yes with continuous oxygen order. This one needs to be modified. 2)Review of Resident #44's MDS's titled Quarterly dated 4/15/2026 Section O Special Treatments, Procedures, and Programs did not document oxygen use.Review of Resident #44's physician order dated 4/12/2026 read, Oxygen: Administer oxygen @ 2L via nasal cannula to keep oxygen saturation greater than 90%. Contact provider if oxygen saturation goes below 90% as needed for Hypoxemia/SOB [shortness of breath].Review of Resident #44's Weights and Vitals Summary documented on 4/14/2026 at 21:54 oxygen saturation was 95% (oxygen via nasal cannula), 4/13/2026 at 21:30 oxygen saturation was 95% (oxygen via mask), 4/13/2026 15:54 oxygen saturation was 96% (oxygen via nasal cannula), 4/13/2026 at 11:09 oxygen saturation was 97% (oxygen via Nasal Cannula), 4/13/2026 at 06:30 oxygen saturation was 96% (Oxygen via Nasal Cannula), 4/12/2026 at 19:25 oxygen saturation was 96% 2L/MIN [liters per minute] (Oxygen via Nasal Cannula), and 4/12/2026 at 12:25 oxygen saturation was 98% 2L/MIN (Oxygen via Nasal Cannula).During an interview on 7/9/2026 at 9:53AM with the MDS Coordinator stated, [Resident #44's name] assessment should be modified, there is documentation of oxygen use.3)Review of Resident #109's MDS titled Quarterly dated 5/21/2026 Section O Special Treatments, Procedures and Programs did not document oxygen use.Review of Resident #109's physician order dated 4/12/2026 read, Oxygen: Administer Oxygen @ 2 L via nasal cannula PRN. as needed for Hypoxemia.Review of Resident #109's Weights and Vitals Summary documented on 5/20/2026 at 22:42 oxygen saturation was 97% (oxygen via Nasal Cannula), 5/18/2026 at 23:09 oxygen saturation was 98% (oxygen via Nasal Cannula), 5/18/2026 at 10:35 oxygen saturation was 98% (Oxygen via Nasal Cannula), and on 5/17/2026 at 23:26 oxygen saturation was 97% (Oxygen via Nasal Cannula).During an interview on 7/9/2026 at 10:03 AM the MDS Coordinator stated, [Resident #109's name] vitals look back period for 5/21 [2026] documented resident was using oxygen. If they would have not documented, that it would have been different. Should be modified since documented oxygen used.During an interview on 7/10/2026 at 8:50 AM the Director of Nursing stated, The facility follows the RAI [Resident Assessment Instrument].

Based on interview and record review the facility failed to update the State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) for 1 (Resident #22) of 4 residents reviewed for behavioral services. Findings include:Review of Resident #22's admission Record resident was first admitted on [DATE] and has diagnosis including but not limited to Major Depressive Disorder [onset date 5/20/2026].Review of Resident #22's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 8/28/2025 did not documented any mental or suspect mental illness.Review of Resident #22 Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 read, Chief Complaint. Depression. History of Presenting Illness. The patient presents today for evaluation of major depressive disorder, recurrent, moderate. They reported symptoms including decrease interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite occurring on more than half of the days. The current episode has persisted for the past three months, also linked to ongoing health concerns. These symptoms are causing the patient moderate subjective distress.During an interview on 7/9/2026 at 10:31 AM with the Director of Nursing (DON) stated, [Resident #22's name] PASSR should have been updated to reflect depression. Balance Wellbeing will be the ones to update that. That is a service they provide to us.Review of the Facility policy and procedure titled Resident Assessment-Coordination with PASARR Program with a last review date of 3/25/2026 read, Policy: This facility coordinates assessments with preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.

Based on interview and record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #22) of 4 residents reviewed for behavioral services. Findings include:Review of Resident #22's admission Record resident was first admitted on [DATE] and has diagnoses including but not limited to Major Depressive Disorder [onset date 5/20/2026].Review of Resident #22's Balance Wellbeing Psychology Evaluation Note dated 5/6/2026 read, Chief Complaint. Depression. History of Presenting Illness. The patient presents today for evaluation of major depressive disorder, recurrent, moderate. They reported symptoms including decrease interest in activities, persistent, depressed mood, sleep disturbances, fatigue, and changes in appetite occurring on more than half of the days. The current episode has persisted for the past three months, also linked to ongoing health concerns. These symptoms are causing the patient moderate subjective distress.Review of Resident #22's Balance Wellbeing Psychology Evaluation Note dated 6/24/2026 read, Chief Complaint: Depression. History of Presenting Illness. The patient is being seen today due to symptoms associated with Major Depressive Disorder, Recurrent, Moderate. The patient shares experiencing a persistent depressed mood along with a marked loss of interest and altered sleep patterns. They also report experiencing fatigue. Overall distress is evaluated as moderate, with symptoms occurring over multiple days.Review of Resident #22's MDS (Minimum Data Set Assessment) titled Quarterly dated 6/13/2026 documented Section I Active Diagnosis of depression.Review of Resident #22's Care Plan did not document a focus area of depression.During an interview on 7/9/2026 at 10:08 AM with the MDS Coordinator stated, [Resident #22's name] has been followed by Balance Wellbeing since 12/2025. The diagnosis was put in on 5/20 [2026]. Depression is not included in the care plan and it should be. I will have to add a focus of depression without medications.During an interview on 7/9/2026 at 12:07 PM the Director of Nursing stated, [Resident #22's name] should be care planned for depression.Review of the facility policy and procedure titled Comprehensive Care Plans with a last review date of 3/25/2026 read, Policy: It is this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interview, and record review, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 residents reviewed (Resident #113) by failing to provide timely post-procedure wound care following a dermatology procedure and by failing to implement physician-ordered aspiration precautions.Findings include:Review of physician orders dated 06/16/2026 revealed Resident #113 was referred to UF Health Dermatology for evaluation and treatment of a skin growth.Review of Resident #113's medical record revealed the resident underwent a dermatology procedure on 07/06/2026 and returned to the facility with dressings covering biopsy sites on the head and face.Review of the Resident #113's Dermatology Visit Summary dated 07/06/2026 revealed wound care instructions that read, Allow any pressure dressing applied by your physician to remain in place for 24 hours. Remove dressing and care for the site as noted below . Clean the wound gently every day with mild soap and water and pat dry. Apply white petrolatum to the wound then cover it with a Band-Aid once a day until the area heals.During an observation on 07/07/2026 at 9:46 AM, Resident #113 was observed resting in bed with dressings covering the biopsy sites on the head and face. The dressings were not dated.During an observation on 07/08/2026 at 1:20 PM, Resident #113 was observed resting in bed with dressings covering the biopsy sites on the head and face. The dressings were not dated.Review of Resident #113's medical record revealed no documentation the biopsy sites were assessed upon the resident's return from the dermatology procedure and no documentation wound care was performed on 07/07/2026 or 07/08/2026.During an interview on 07/08/2026 at 1:35 PM, the Director of Nursing (DON) stated that when a resident returns from a procedure, she expects nursing staff to provide wound care as ordered by the physician. She further stated that if a resident returns without wound care instructions, nursing staff are expected to contact the physician to obtain wound care orders.Review of Resident #113's medical record revealed a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) performed on 04/29/2025 demonstrated silent penetration with straw sips of thin liquids.Review of Resident #113's physician orders dated 11/03/2025 revealed the resident was ordered an easy-to-chew diet with no straws.Review of Resident #113's care plan revealed the resident had dysphagia and instructed staff not to provide beverages with a straw.During an observation on 07/09/2026 at 8:30 AM, Resident #113 was observed drinking water from a cup containing a straw.During an interview on 07/09/2026 at 8:31 AM, Staff G, CNA stated, Well how else are we supposed to give him a water cup, we have to provide water.During an interview on 07/09/2026 at 9:30 AM, the Speech-Language Pathologist (SLP) stated the resident's FEES demonstrated silent penetration with straw use. She stated the resident was then placed on a no-straw precaution.During an interview on 07/09/2026 at 11:40 AM, the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia to reduce the risk of aspiration.

Based on observation, interview and record review the facility failed to follow standards of care for oxygen use when failing to provide accurate oxygen flow rate and change tubing weekly for 2 (Resident #5 and #6) of 7 residents reviewed for respiratory services. Findings include: 1)During an observation on 7/7/2026 at 10:10 AM Resident #5 was not in her room. There was an oxygen concentrator machine in the room. The oxygen tubing was stored in a bag hanging from the oxygen concentrator. The tubing was dated 6/26.During an observation on 07/08/2026 at 8:35 AM Resident #5 was lying in bed being administered oxygen via nasal cannula at 3 liters per minute. The oxygen tubing was dated 6/26. During an observation on 7/9/2026 at 8:02 AM Resident #5 was lying in bed. Resident #5's oxygen was running at 3 liters and tubing was dated 6/26.During an interview on 7/9/2026 at 8:21 AM Staff F Registered Nurse (RN) confirmed Resident #5's tubing was dated 6/26 and oxygen was being administered at 3 Liters.Review of Resident #5 physician order dated 1/7/2025 read, Oxygen: Administer Oxygen @ _2_L via nasal cannula, Continuous. every shift for infiltrate of left lung. During an interview on 7/9/2026 at 8:21 AM with Staff F, RN, stated, Oxygen tubing gets changed every week by a respiratory therapist that comes into the building. The tubing should have been changed last week. [Resident #5's name] is running at 3 liters but has orders for 2 liters of oxygen.2)During an observation on 07/07/2026 10:10 AM Resident #6 was lying in bed. The resident was being administered oxygen at 4 liters per minute. During an observation on 07/07/2026 at 12:12 PM Resident #6 was lying in bed. Oxygen was being administered at 4 liters per minute via nasal cannula. During an observation on 7/8/2026 at 8:02 AM Resident #6 was lying in bed. Oxygen was being administered at 4 liters per minute via nasal cannula.Review of Resident #6's physician order dated 3/18/2026 read, Oxygen: Administer Oxygen @ 3L via nasal cannula continuous. every shift for Chronic Respiratory Failure with Hypoxia.During an interview on 7/9/2026 at 8:18 AM Staff F RN entered Resident #6's room and confirmed resident's oxygen was being administered at 4 liters.During an interview on 7/9/2026 at 8:18 AM Staff F Registered Nurse stated, [Resident #6's name] has orders for oxygen at 3 liters. It should not be at 4 liters.During an interview on 7/9/2026 at 12:16 PM the Director of Nursing stated, Nursing staff should check oxygen flow rate every shift and as needed. The tubing should be changed weekly. We have a respiratory therapist who changes the tubing.Review of the facility policy and procedure titled Oxygen Administration with a last review date of 3/25/2026 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 5.b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on observation, interview, and record review the facility failed to follow professional standards of practice leaving on attended medication in 1 of 4 hallways and in dinning room area and expired medication in 1 of 5 medication carts. Finding include: During an observation on [DATE] at 9:34 AM Resident #36 was lying in bed. Behind a picture frame on top of the nightstand there was a clear medication cup with a white cream. [photographic evidence obtained] During an interview on [DATE] at 9:34 AM Resident #36 stated, The nurses apply that cream to my groin area. During an interview on [DATE] at 10:08 AM Staff C Registered Nurse stated, [Resident #36's name] is not able to self-administer medication. During an interview on [DATE] at 10:17 AM with Staff D, Certified Nursing Assistant stated, I went in to change [Resident #36's name] and she told me she had cream on her nightstand. Nurses are the ones who are supposed to apply that, they are not to leave it at bedside. 2) During an observation on [DATE] at 9:57 AM Resident #24 was sitting up in bed. There was a medication cup on top of the bedside table with two white circular tablets. During an interview on [DATE] at 9:57 AM with Resident #24 stated, The nurse left this medication for me to take. It is for gases and over the counter. During an interview on [DATE] at 10:03 AM with Staff C, RN, stated, Resident #24 is not able to self-administer medication. He takes Simethicone at night, I have not administered any medication this morning. During an interview on [DATE] at 10:03 AM Staff C, RN, entered Resident #24's room and confirmed medication was unattended at bedside. 3) During an observation on [DATE] at 9:00AM Resident #21 was sitting in the memory care dining room eating breakfast. There was a medication cup with a total of five tablets on the table. The nurse was at the left side corner of the entrance of the dining room with his back towards the residents facing his medication cart. During an interview on [DATE] at 9:07 with Staff E, LPN stated, [Resident #21's name] is really good at taking her medication. I thought she had taken all her medications before I walked away. I thought we were good, but we were not. Staff E confirmed Resident #21 had medication still inside the medication cup next to her breakfast. During an interview on [DATE] at 12:22 PM with the Director of Nursing stated, When staff are administering medications they are to stay with the resident and make sure the medications are consumed. [Resident #24's name] and [Resident #21's name] are not able to self-administer medication. Medications are not to be left unattended. During an observation on [DATE] at 9:17 AM with Staff H, Licensed Practical Nurse (LPN) of the Garden Gate Hallway Medication Cart there was two expired bottles of Brimonidine Tartrate Ophthalmic Solution 0.2% with an open date of [DATE] and one with an open date of [DATE] and one expire bottle of Olopatadine Hydrochloride Ophthalmic Solution with an open date of [DATE]. During an interview on [DATE] at 9:20 AM Staff H, LPN, stated Normally open eye drops will be good for 30 days. Expired medication should be discarded. During an interview on [DATE] at 9:19 AM the Director of Nursing stated, The eye drops were expired. Normally expired medication should be disposed and reordered. Review of the facility policy and procedure titled Medication Storage with a last review date [DATE] read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn. illegible, or missing labels, These medications are destroyed in accordance with out destruction of Unused Drugs Policy. Review of Ophthalmic Medications Beyond-Use Date Guide read, From the Centers for Medicare and Medicaid Services (CMS). If the manufacturer does not provide stability data for once the preparation is opened, current practice guidelines recommend to discard the medication after 28 days due to concerns of stability and sterility. The following chart list several ophthalmic medications for which the manufacture has been contacted to determine the expiration date once the preparation has been opened. This list may not be inclusive. Florida Pharmaceutical Product. Brimonidine Sol 0.2% OP Expiration Date. 28 days from opening.

Based on record review and interview, the facility failed to ensure physician-ordered laboratory services were provided for 1 of 1 residents reviewed for laboratory monitoring (Resident #13).Findings include:Review of Resident #13's physician's orders dated 06/26/2025 revealed an order for Levothyroxine Sodium 137 mcg (Microgram), give one tablet by mouth daily for low thyroid hormone, repeat TSH (Thyroid Stimulating Hormone) in three weeks.Review of Resident #13's medical record revealed the ordered thyroid-stimulating hormone (TSH) laboratory test was not obtained. Resident #13 continued to receive levothyroxine therapy without the physician-ordered laboratory monitoring.Review of Resident #13's consultant pharmacist's monthly medication regimen review dated April 2026 recommended a TSH level recheck in six months to one year. Review of the medical record revealed no documentation the recommended laboratory monitoring had been completed.Review of Resident #13's physician progress notes from January 2026 through July 2026 revealed no documentation indicating the physician discontinued or modified the original order to obtain the TSH laboratory study.During an interview on 07/09/2026 at 9:50 AM, the ADON (Assistant Director of Nursing) stated the resident's last TSH was obtained in 2024, and was unsure why follow-up laboratory testing had not been completed.During an interview on 07/10/2026 at 8:30 AM, the DON (Director of Nursing) stated she would have expected the TSH laboratory order to have been entered.During an interview on 07/10/2026 at 8:45 AM, Physician #1 stated the TSH order should have been placed.

Based on record review and interview, the facility failed to ensure 3 out of 4 Residents (Resident #3, #118 and #120) reviewed for discharge had a discharge order in their medical record. Findings include: Review of medical record for Resident #120 shows admittance to the facility on [DATE] for diagnosis of, but not limited to Type I diabetes mellitus with hyperglycemia, gastroparesis, muscle weakness, unsteadiness on feet, need assistance with personal care, schizophrenia, depression, hypothyroidism of coordination, other lack abnormalities gait and mobility, hyperlipidemia, anemia, essential primary hypertension, cognitive communication deficit, dysphagia oropharyngeal, and long-term use of insulin. Review of Resident #120's Health status note dated 5/15/26 reads, Resident discharged back to ALF (Assisted Living Facility) in stable condition. Vital signs stable (VSS), afebrile, and skin intact. Discharge instructions provided and explained, including administration of long-acting and short-acting insulin. Resident/caregiver verbalized understanding. Sent with all personal belongings. Transportation arranged and provided by facility staff. During an interview on 7/8/26 at 11:30AM the Director of Nursing stated, We did not obtain orders for discharge. Review of medical record for Resident #3 shows admittance to the facility on 3/4/26 with diagnoses of Hyperkalemia, lack of coordination, encounter for attention of gastrostomy, hypertensive chronic kidney disease with stage 1 through stage 4, Acute kidney failure, type 2 diabetes mellitus with diabetic chronic kidney disease, COPD, atherosclerotic heart disease of native coronary artery, anemia in chronic kidney disease, muscle weakness, psoriasis, hyperlipemia, major depressive disorder, insomnia, presence of aortocoronary, peripheral vascular angioplasty status with implants and grafts, and nicotine dependence. Review of Resident # 3's progress noted dated 3/8/26 shows it read, MD(Doctor) reviewed labs, MD order resident sent to hospital for (not completed in record). During interview on 7/9/26 at 12:04PM the Director of Nursing stated, Paperwork for [Resident #3's Name] had been completed for discharge, but no physician order was written. Record review of medical record for Resident #118 shows an admittance to the facility on [DATE] for diagnoses of but not limited to metabolic encephalopathy, Type 2 diabetes mellitus, hypertensive heart disease with heart failure, dysphagia following cerebral vascular accident (CVA), muscle weakness, and dysphagia. During an interview on 07/10/2026 at 08:50 AM the DON stated All verbal orders should have a written order in the Residents record for discharge, whether going to the emergency room or being discharged to the community. If a resident is discharged from the facility they should have an order for the discharge in their medical record. Record review of Resident #118's progress note dated 05/20/2026 at 11:36 PM reads, Nurse assessed resident and vitals were not within normal limits, resident was visibly in respiratory distress and altered mental status. Medical Doctor (MD) was notified and ordered to send to emergency room (ER). Review of Resident #118's physician orders does not reveal an order to be transferred from the facility to the hospital. Review of the facility policy and procedure titled Transfers and Discharge (including AMA) dated March 25, 2026, showed it read, Policy Statement: It is our policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payer source. Guidelines for Emergency Transfers to Acute Care, the facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. Guidelines for Anticipated and Discharge to the Community, Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care.

Based on observation, interview, and record review the facility failed to follow infection control standards for hand hygiene for 2 of 5 medication administration observations and failed to follow infection control standards for storage of tubing and nebulizer treatment pieces for 3 (Resident #2, #45, and #121) of 7 residents reviewed for respiratory services. Findings include: 1)During an observation on 7/9/2026 at 8:22 AM Staff B Registered Nurse (RN) was pouring medication for Resident #110. Staff B poured a white circular pill into her hand from the medication blister pack and poured the medication into the medication administration cup. Staff B entered Resident #110's room and administered the medication to the resident. During an observation on 7/9/2026 at 8:24 AM Staff B, RN performed hand hygiene, placed a tissue as a barrier and on top of the tissue placed a clear medication cup. Staff B began to pour medication for Resident #79. Staff B was pouring Hydroxychloroquine Sulfate Oral Tablet 200 MG [milligram] and the tablet fell onto the top medication cart. Staff B grabbed the tablet Hydroxychloroquine and disposed of the medication. Staff B without performing hand hygiene continue to pour medications. A tablet of Eliquis fell onto the tissue that was being used as a barrier and Staff B without wearing gloves grabbed the tablet of Eliquis and poured the medication into the medication cup. Staff B poured a tablet of Divalproex Sodium into her hand and then placed the tablet into the medication cup. Staff B finished pouring all the medication into the medication cup and proceeded to enter Resident #79's room and administer the medication. Review of Resident #79's physician order dated 4/15/2026 read, Hydroxychloroquine Sulfate Oral Tablet 200 MG (Hydroxychloroquine Sulfate) Give 1 tablet by mouth in the morning for lupus. Review of Resident #79's physician order dated 7/4/2026 read, Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give Alternating Dose of 1 tablet/2 tablet by mouth two times a day related to other seizures (G40.89) Take 1 tablet in the morning and 2 tablets at bedtime. Review of Resident #79's physician order dated 7/8/2026 read, Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT. During an interview on 7/9/2026 at 8:47 AM with Staff B, Registered Nurse stated, I should have performed hand hygiene after disposing of the table that fell onto the top of the medication cart. I thought if my hands are clean, I could touch the medication without using gloves. During an interview on 7/9/2026 at 12:19 PM with the Director of Nursing stated, Staff should not be popping the medication into their hands. If the medication falls on top of the barrier the staff should use gloves when touching medication and should perform hand hygiene after disposing of medication before continuing to pour medication. Review of the facility policy and procedure titled Medication Administration with a last review date of 3/25/2026 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 14. Remove medication from source, taking care not to touch medication with bare hand. 20. Wash hands using facility protocol and product. Review of the facility policy and procedure titled Hand Hygiene with a last review date of 3/25/2026 read, Policy: All Staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand Hygiene Table. Before preparing or handling medications. 2) During an observation on 7/9/2026 at 8:35 AM Staff B, RN, entered Resident #45's room and removed a Nebulizer T-Mouthpiece from a gray plastic basin located on top of the nightstand. The mouthpiece was not stored in a bag. Staff B poured the Albuterol Sulfate Nebulization solution and handed the nebulizer to Resident #45 to provide the treatment. Review of Resident #45 physician order dated 12/27/2025 read, Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml [milliliter] inhale orally via nebulizer three times a day for Shortness of Breath. During an interview on 7/9/2026 at 8:47 AM Staff B, RN stated, Normally the nebulizer mouthpiece is stored in a bag when not in use. The mouthpiece was not bagged. I should have gotten a new one and discarded the one not bagged before giving the treatment. During an interview on 7/9/2026 at 12:18 PM the Director of Nursing stated, The nebulizer mouthpiece and mask should be stored in a bag when not in use. The staff should have disposed of the mouthpiece and gotten a new one. Review of the facility policy and procedure titled Oxygen Administration with a last review date of 3/25/2026 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences. Policy Explanation and Compliance Guidelines: e. Keep delivery devices covered in plastic bag when not in use. 3)Record Review of medical records reveals Resident #2 was admitted on [DATE] with diagnoses of but not limited to hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, type two diabetes, and anemia. During an observation on 07/07/26 at 9:10 AM Resident #2's bedside table, a nebulizer mask was sitting next to the nebulizer machine. The machine was not currently running. The mask was left open to air, not being secured in a labeled bag. Photo documentation provided. During an observation on 07/09/26 at 08:50 of Resident #2's empty room the bed is made. On the bedside table, a nebulizer mask is located next to the machine, not covered appropriately. Photo documentation provided. During an interview on 07/09/2026 at 12:20 PM the DON stated, My expectations for the staff who administer the nebulizer is to store the equipment in a bag labeled for the Resident when the nebulizer mask and tubing is not in use. If identified the equipment had not been stored appropriately, the equipment should have been removed and switched out for new equipment. Record review of orders for Resident #2 read on 05/01/2026 at 02:56 AM order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for COPD. Review of the MAR indicates this medication has been given for the month of July on the 2nd at 08:52 AM, the 6th at 10:22 AM, the 7th at 1:59 PM, and the 8th at 3:12 PM.

Based on interview and record review, the facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use for 1 (Resident #1) of 5 residents with wound care needs.On August 3 and 4, 2025, [Brand Name] Wound Care Cleanser was observed unattended in Resident #1's room at different times by three staff members. The wound cleanser was not removed. Resident #1 consumed the wound cleanser, complained of burning to his mouth and stomach resulting in Resident #1 being transferred to a higher level of care.The facility failed to ensure residents were free from accidents and hazards by failing to ensure wound cleanser containing chemicals were secure when not in use led to the determination of Immediate Jeopardy at a scope and severity of isolated, (J). The facility's actions placed Resident #1, who had a diagnosis of dementia, at a likelihood of serious harm, such as gastrointestinal irritation, nausea, vomiting, or diarrhea. The Administrator in Training was provided the Immediate Jeopardy Template on August 12, 2025 at 4:09 PM. The Immediate Jeopardy began on August 4, 2025 and was removed on site on August 6, 2025.Findings include: During an interview on August 11, 2025 at 9:00 AM, the Director of Nursing (DON) stated, I was notified on 8/5, [August 5, 2025] that a resident [Resident #1] had potentially ingested wound cleanser by the night shift nurse. He [Resident #1] reported to the nurse he had drank some [wound cleanser] and his mouth was burning. He did not say why only stated he knew it was wound cleanser, and he drinks whatever is in front of him. He is still in the hospital as far as I am aware. He went to [Name of Hospital]. He was a short-term patient. I have not heard any updates. His wife came in Friday and got his belongings. We don't typically leave wound cleanser in the room. A newer Licensed Practical Nurse (LPN) took the wound cleanser in the room. The MD [Medical Doctor] and poison control informed the nurse to send him out for eval [evaluation] due to the ingredients and due to his throat burning. Poison control compared it to potential laundry soap. He [Resident #1] came in Friday afternoon and this happened on Monday. He was in an isolation room.During an interview on August 11, 2025 at 2:40 PM, Staff E, Certified Nursing Assistant (CNA) stated, I worked the four hour shift that day, 7:00 pm to 11:00 pm. I notified the nurse [Staff C, Licensed Practical Nurse] that the wound cleanser was in the room because I was assisting the resident to the bathroom and it fell off the bedside table. When asked why she did not remove it from the room she stated, I was not sure why she [the nurse] did not remove it, maybe because I thought the nurse was not through with it or had left it for later. I really don't know why I did not remove it.During an interview via telephone on August 11, 2025 at 2:42 PM, Resident #1's physician stated, It was life-threatening and could have been worse. The staff called the poison control and due to the ingredients poison control recommended he be sent to the hospital and that is what the facility did.During a telephone interview on August 11, 2025 at 2:44 PM, Staff A, CNA, stated, The resident [Resident #1] was in the isolation room, and I had just come back from break and went to check on him and he was lying in bed, and he stated his mouth was burning and he held up the bottle and read it to me: ‘wound cleanser' and that he had been ‘drinking wound cleanser.' I took the wound cleanser from him and notified the nurse who then called someone, not sure who, if it was the doctor or poison control. EMS [Emergency Management Services] arrived 20 to 30 minutes later. During an interview on August 11, 2025 at 3:18 PM, Staff D, CNA, stated, I saw the wound cleanser in the room that day [August 4, 2025]. When asked why she did not remove it from the room she stated, We as CNAs are not allowed to touch it, only nurses. I notified his nurse, Staff C, LPN, who stated she would take care of it.During an interview on August 12, 2025 at 11:54 AM, Staff E, CNA, stated, I had come on [August 4, 2025 at] 7pm - 11PM to work and it was sometime around 8PM - 8:30 PM when his [Resident #1] bed alarm started going off. I walked into his room, and he was walking to the bathroom, and he didn't seem very stable. His bedside table was in the path to the bathroom. I stepped around it to get to him and the wound cleanser fell to the ground. After, I got him back in bed. I put the wound cleanser back on the table because I didn't think anything about it because CNAs do not do wound care. I know that I should have just taken it out of the room. I was not told in report that he tried to drink urine or anything else of the sort. He didn't show any signs like that when I was taking care of him. He was trying to urinate in the sink. I only worked four hours that night and had no additional encounters with him.During an interview on August 12, 2025 at 12:14 PM, Staff C, LPN, stated The day before he drank the wound cleanser, I was his nurse. The CNA [Staff D] came to me and told me he was trying to drink his urine. I went to the room and went to move the urinal out of the way. The wife was at bedside and said no don't do that he needs it there. I called the doctor and told him that he was trying to drink his urine. The doctor told me he has a history of that it is in the records from the hospital and to increase his Trazadone. The care plan was updated by [Director of Nursing's Name]. The care plan was not updated by me; it was done by her [Director of Nursing]. The reason they care planned it was because he tried to drink the urine and that they were told by the wife to leave the urinal there and not to move it even if he drinks it. The care plan was to leave the urinal at bedside. His wife said he wanted it right there and that is why we care planned it. I was aware before he drank the wound cleanser that no medications or biologicals including wound cleanser were allowed at the bedside, but I didn't if think about wound cleanser, I know now.During an interview on August 12, 2025 at 2:05 PM, the Assistant Director of Nursing stated, We provide training on hire that no medications or biologicals can be left at bedside unsecured.During an interview on August 12, 2025 at 2:08 PM, the Director of Nursing stated, We educate quarterly and during orientation that medications, treatments, and biologicals cannot be left at bedside unattended. All staff had been educated prior to this incident, and we are reeducating now.Review of Resident #1's electronic clinical records showed Resident #1 was admitted to the facility on [DATE] with diagnoses that included: other viral pneumonia; orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down); chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath); hypertensive heart failure and chronic kidney disease (heart failure that develops as a consequence of high blood pressure and long standing disease of the kidneys leading to renal failure); chronic systolic congestive heart failure (occurs when the heart's main pumping chamber, the left ventricle, weakens and can't contract forcefully enough to pump sufficient blood throughout the body); chronic kidney disease; anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin a protein found in red blood cells, to carry oxygen through the body) in chronic kidney disease; atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls); chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow); unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; hyperlipidemia (a condition where there are elevated levels of fats in the blood); hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone); insomnia (a common sleep disorder characterized by difficulty falling asleep); unspecified glaucoma (a group of eye conditions that can cause blindness); and presence of cardiac pacemaker (a small battery powered electronic device implanted in the chest to help regulate a slow heartbeat).Review of Resident #1's interim care plan, initiated 8/3/2025, documented Resident #1 had impaired visual function, limited physical mobility or was at risk for mobility decline, was resistive to care and refused treatments, would consume liquids that are not considered drinkable, was prescribed antianxiety, diuretic, hypnotic and antidepressant medications, and was at risk of suffering from pain.Review of the facility investigation file, incident date August 4, 2025, revealed Resident #1 was admitted to the facility on [DATE]. At approximately 9:00 PM on August 4, 2025 was found to be ingesting wound cleanser in his room by Staff A, CNA. It was unknown where Resident #1 acquired the wound cleanser. The total amount consumed was unknown, however, the bottle was 8 ounces total. Resident #1 knew the bottle contained wound cleanser based on the statements Resident #1 made to Staff A, CNA including Oh this is wound cleanser, it burns. As a precaution, Resident #1's physician was contacted. Resident #1's physician advised to monitor Resident #1. Staff B, Registered Nurse, reached out poison control. Resident #1 was taken to the hospital for treatment.Review of Resident #1's electronic clinical records revealed a change of condition evaluation, dated August 5, 2025 at 22:26 [10:26 PM], that documented Resident #1 was noted to have consumed an 8 ounce bottle of wound cleanser and concluded confusion lead to unknowingly consuming wound cleanser. The change of condition evaluation documented Resident #1's abdominal/gastrointestinal symptoms of abdominal pain and oral cavity mouth burning. The change of condition evaluation documented Resident #1 continued moaning stating his mouth was burning and his stomach was burning, and Resident #1 was noted to have excessive secretions, for example, spit coming from his mouth.Review of Resident #1's electronic clinical records revealed a transfer form, dated August 4, 2025, that documented Resident #1 was transferred to the hospital following ingestion of wound cleanser.Review of Resident #1's hospital records, dated August 4, 2025, revealed Resident #1's visit diagnosis as ingestion of substance, undetermined intent, initial encounter (primary). The hospital report documented When asked why he drank this patient states, I do not know, I do not know anything. The hospital report documented Resident #1 was placed under [NAME] Act and will require admission for observation and acute kidney injury. Assessment and Plan: Acute chemical ingestion (dermal wound cleanser) posing a threat to bodily function in the near term without treatment. Hx [History] of dementia. Discussed with poison control, no further guidance. Continue to monitor for GI [gastrointestinal] upset/mouth irritation.Review of the [Brand Name] Material Safety Data Sheet for the wound cleanser read, Section 2 Hazard Identification. Overview. A personal care product that is safe for use by consumers under all normal and intended circumstances. Health Effects: Contact with the eyes may cause minor irritation, redness or stinging. Contact with skin should not be irritating when used as intended. It is not expected to be irritating to the respiratory system through inhalation. An accidental ingestion of this product may cause gastrointestinal irritation, nausea, vomiting or diarrhea. Section 4. First Aid Measures. Ingestion: The accidental ingestion of the product may necessitate medical attention. In the case of ingestion, dilute with fluids and do not induce vomiting. In the event of an extreme case of ingestion consult a physician or local poison control center.The Immediate Jeopardy (IJ) was removed onsite as of August 6, 2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. On August 5, 2025 the facility held a Quality Assurance and Performance Improvement (QAPI) meeting and completed a root cause analysis (RCA) related to the unsecured chemical (wound cleanser) in Resident #1's room. The RCA yielded that an unidentified staff member failed to follow the facility policy and left the unsecured wound cleanser in Resident #1's room accessible to Resident #1. On August 5, 2025 immediate education was overseen by the Director of Nursing and completed with 143 of 145 staff members regarding proper storage and/or removal of unsafe substances from Resident's rooms. On August 5, 2025 immediate education was overseen by the Director of Nursing and completed with 31 nursing staff (12 Registered Nurses and 14 Licensed Practical Nurses) regarding proper use and storage of treatment cleansers or any other items deemed harmful or hazardous. On August 5, 2025 education overseen by the Director of Nursing was completed with nursing staff to include room rounds with shift change report to ensure resident safety related to wound cleanser and or biologicals unattended or in reach of residents.On August 13, 2025, a review of facility audits documented an initial audit overseen by the Director of Nursing of all residents' rooms for unsecured hazardous and potentially hazardous products was completed on August 5, 2025.On August 13, 2025, a review of facility audits completed by Unit Managers through August 6, 2025 documented Unit Managers were auditing each room daily to verify there were no biologicals found in the residents' rooms.On August 13, 2025, a review of facility training records documented a total of 31 nursing staff members (including 12 Registered Nurses and 14 Licensed Practical Nurses) were forwarded electronic training overseen by the Director of Nursing on August 5, 2025 related to the standard of not leaving any type of medication or treatment at residents' bedsides unsupervised.During staff interviews conducted August 11, 2025 through August 13, 2025, 1 Minimum Data Set Registered Nurse, 7 Registered Nurses, 14 Certified Nursing Assistants, 1 Assistant Director of Nursing, 4 Licensed Practical Nurses, 1 Maintenance Director, 1 Social Worker, 1 Housekeeping Director and 2 dietary aides all verified receiving education and verbalized understanding of the importance of securing potentially hazardous substances and not leaving potentially hazardous substances in residents' rooms or leaving the potentially hazardous substances accessible to residents.

Based on record review and interview, the facility failed to ensure the minimum data set (MDS) was completed accurately for 1 of 3 residents, Resident #104 reviewed for hospitalization . Findings include: Review of Resident #104's medical record revealed a form titled Release of Responsibility on Leave of Absence which documented the resident signed herself out on a leave of absence on 2/2/25 at 12:35 PM. Review of Resident #104's MDS (Minimum Data Set) Resident Assessment and Care Screening Nursing Home discharge date d 2/11/25 read, Section A - Identification Information A2105, Discharge Status Enter Code 04. 04. Short-Term General Hospital. Review of the Skilled Note dated 2/2/25 at 5:37 pm for Resident #104 read, Comments/Narrative Section . Resident left with family at 12:30 to retrieve clothes from home and has yet to come back. She took all belongings with her when she left. Resident advised to be back to facility by 11 pm and verbalized positive understanding. I called and informed resident's daughter, [Daughter's name], that resident was signing out of facility, and she verbalized positive understanding. Review of the Action Summary report read, [Resident #104's name] Discharge Status: discharged to home or self care. Eff [Effective] Date 2/2/2025. Time: 12:00 PM. During an interview on 3/4/25 at 1:15 PM, the Minimum Data Set (MDS) Coordinator verified the information documented on the MDS Resident Assessment and Care Screening Nursing Home discharge date d 02/11/2025 was inaccurate.

Based on record review and interview, the facility failed to develop for implementation a comprehensive care plan to meet the needs for respiratory care services for 2 of 7 residents, Residents #50 and #33, reviewed for respiratory care services. Findings include: 1) During an observation on 3/3/25 at 9:40 AM there was a continuous positive airway pressure (CPAP) machine on Resident #50's bedside table, there was tubing and a mask attached. There were two 1-gallon bottles of sterile water observed on the floor next to Resident #50's bed. (Photographic evidence obtained). During an observation on 3/4/25 at 3:15 PM there was a CPAP machine on the bedside table in Resident #50's room. The face mask was attached to the tubing on the machine. (Photographic evidence obtained). During an interview on 3/4/25 at 3:40 PM, Resident #50 stated, I wear that [CPAP machine] every night. The staff do not help me with it. I believe they knew about it when I brought it in. Review of Resident #50's medical record documented the resident was admitted into the facility on [DATE] with medical diagnosis to include obstructive sleep apnea (a sleep disorder characterized by recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to interrupted breathing), Type 2 diabetes mellitus with other specified complication; essential (primary) hypertension. Review of Resident #50's physician orders did not contain an order for the CPAP machine or respiratory therapy services. Review of Resident #50's MDS [Minimum Data Set] Admission Evaluation, dated 2/7/25 read, Section I: Additional active ICD diagnosis 2: G47.33 Obstructive Sleep Apnea (Adult). Section O: C1. Oxygen Therapy - No. Review of Resident #50's care plan, dated 2/12/25, did not contain a focus pertaining to Resident #50's diagnosis of obstructive sleep apnea, and nightly use of a CPAP machine. 51447 2) During an observation on 03/04/2025 at 12:28 PM of Resident #33 it showed she was sitting in bed eating lunch with oxygen being administered at 3 liters per minute via nasal cannula. Review of the physician order dated 12/17/2024 for Resident #33 read, Administer oxygen at 3 Liters per minute (humidified) via nasal cannula continuously. Review of Resident #33 care plan dated 02/19/2025 did not contain a focus pertaining to the resident's respiratory care need for continuous oxygen. During an interview conducted on 03/06/2025 at 10:05 AM the Director of Nursing (DON) stated, My expectations would be that residents with respiratory needs would have that included on their comprehensive care plan. The DON reviewed Resident #50 and Resident #33's comprehensive care plans and verified the care plans did not contain a focus related to Resident #50 and Resident #33's respiratory needs. Review of the policy and procedure titled Comprehensive Care Plans, last reviewed on 2/19/25, read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician for 1 of 7 residents, Resident #89 Findings include: Review of Resident #89's admission record dated 3/1/24 documented diagnoses that included other disorders of lung, gastrointestinal hemorrhage, unspecified systolic (congestive) heart failure unspecified atrial fibrillation, and dependence on supplemental oxygen. Review of Resident #89's physician orders dated 5/17/24 read, Observation: oxygen therapy observe for signs and symptoms of cyanosis, hypoxia, and oxygen toxicity: oxygen: administer oxygen at 2L/min. [2 liters per minute] During an observation on 03/03/25 at 10:56 AM Resident #89 was observed resting in bed with oxygen being administered at 4 liters per minute via nasal cannula. The oxygen concentrator was at the head of the bed on the resident's right side, outside of the reach of the resident. During an observation on 03/03/25 at 1:30 PM Resident #89 was observed resting in bed with oxygen being administered at 4 liters per minute. The oxygen concentrator was at the head of the bed on the resident's right side, outside of the reach of the resident. During an observation of Resident #89 on 3/4/25 at 10:15 AM with Staff B, Certified Nursing Assistant (CNA). Staff B verified the oxygen was being administered at 4 liters per minute. During an interview on 3/5/25 at 10:12 AM Resident #89 stated, I do not know how to change the levels [oxygen]. During an interview on 3/4/25 at 10:16 AM Staff C, Registered Nurse (RN) stated, That is not correct [the oxygen administration]. It should not be on 4 liters it is ordered for 2 liters. [Resident 89's name] does not change the levels. The oxygen level should be checked at the beginning of every shift, I just have not checked it yet. Review of Resident #89's medical record progress notes for the period of 2/19/25 through 3/5/25, did not provide for documentation for the need to increase the resident's oxygen or a change in the resident's respiratory status. Review of Resident #89's care plan dated 3/4/24 read, [Resident #89's name] receives oxygen therapy, oxygen settings : O2 [oxygen] at 2L via nasal cannula. Interventions: Administer oxygen as ordered. Review of the policy and procedure titled, Oxygen Administration with an implementation date of 12/2024 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice 1. Oxygen is administered under order of a physician, except in the case of an emergency.

Based on interview, observation, and record review the facility failed to enusre physician supervision of medical care for 1 of 7 residents, Resident #50, reviewed for respiratory care. Findings include: During an observation on 3/3/25 at 9:40 AM there was a continuous positive airway pressure (CPAP) machine on Resident #50's bedside table, there was tubing and a mask attached. There were two 1-gallon bottles of sterile water observed on the floor next to Resident #50's bed. (Photographic evidence obtained). During an observation on 3/4/25 at 3:15 PM there was a CPAP machine on the bedside table in Resident #50's room. The face mask was attached to the tubing on the machine. (Photographic evidence obtained). During an interview on 3/4/25 at 3:40 PM, Resident #50 stated, I wear that [CPAP machine] every night. The staff do not help me with it. I believe they knew about it when I brought it in. Review of Resident #50's physician orders did not contain an order for the CPAP machine or respiratory therapy services. Review of Resident #50's medical record documented the resident was admitted into the facility on [DATE] with medical diagnosis to include obstructive sleep apnea (a sleep disorder characterized by recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to interrupted breathing), Type 2 diabetes mellitus with other specified complication; essential (primary) hypertension. During an interview on 3/4/25 at 1:45 PM, Staff D, Registered Nurse (RN) stated, We don't currently have any residents on CPAP. I would confirm the order before putting it on. If a resident came in with a CPAP machine, we need to confirm the order with the physician. [Resident #50's name] is super independent. I don't see an order [for the CPAP machine]. During an interview on 3/4/25 at 1:48 PM, Staff E, Licensed Practical Nurse (LPN) - Unit Manager, stated, I don't remember being told she [Resident #50] had one [a CPAP machine]. She does not have an order [for a CPA machine]. She is diagnosed with sleep apnea. We will call the doctor to confirm he wants it and get an order. During an interview on 3/4/25 at 1:52 PM, the DON stated, For residents on CPAP, Respiratory follows them and we have orders. The nurse ensures they [residents] are wearing them or refusing. Review of Resident #50's MDS [Minimum Data Set] Admission Evaluation, dated 2/7/25 read, Section I: Additional active ICD diagnosis 2: G47.33 Obstructive Sleep Apnea (Adult). Section O: C1. Oxygen Therapy - No. Review of the policy and procedure titled Oxygen Administration, implemented on 12/24, and last reviewed on 2/19/25, read Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . Types of delivery systems include: . d. CPAP Mask - This mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have different settings.

Based on record review and interview the facility failed to ensure the minimum data set (MDS) was completed accurately for 1 of 3 residents, Resident #104, reviewed for discharge. Findings include: Review of Resident #104's care plan, with an initiation date of 9/29/2023, read, Resident wished to be discharged to the community. Resident #104's care plan included discharge planning interventions that included discharge teaching with resident, family; caregivers, engage resident, family and caregivers in discharge planning; establish a pre-discharge plan with the resident/family/caregivers; review with resident discharge goals and discuss appropriate interventions to achieve goals. Review of Resident #104's progress note, dated 10/12/2023, revealed Resident #104 was planning to discharge home this afternoon. Review of Resident #4's MDS Summary Discharge Return Not Anticipated, dated 10/12/2023, read, Section A. Identification Information F. Entry/discharge reporting 10. Discharge - return not anticipated and G. Type of Discharge 2. Unplanned. During an interview on 11/8/2023 at 12:05 PM, the Administrator confirmed Resident #104's Discharge Return Not Anticipated MDS had been coded incorrectly. Resident #104's Discharge Return Not Anticipated MDS should have been coded as a planned discharge.

Based on record review and interview the facility failed to develop and implement a comprehensive care plan to meet the needs for urinary tract infections for 1 of 3 residents, Resident #80. Findings include: Review of the medical record for Resident #80 documents diagnoses that include history of uterine prolapse, diverticulosis of large intestine, acute post hemorrhagic anemia, iron deficiency anemia, essential primary hypertension, gastroesophageal reflux disease, and history of venous thrombosis and embolism. During an interview on 11/06/23 at 1:44 PM Resident #80 stated, I have had several UTI's [urinary tract infections]. I just finished antibiotics for one. Review of the laboratory results document dated 10/23/2023 a urine culture result of greater than 100,000 CFU (colony forming units) with a final result of Escherichia Coli. Dated 8/23/202 a urine culture of greater than 100,000 CFU with a final result of Escherichia Coli. Dated 7/4/2023 a urine culture result of greater than 100,000 CFU with a final result of Escherichia Coli and dated 6/19/2023 a urine culture result of greater than 100,000 CFU with a final result of Escherichia Coli. Review of Resident #80's care plan did not contain a plan of care for urinary tract infections with measurable objectives, interventions, and timetables to meet the resident's needs. During an interview conducted on 11/8/2023 at 9:50 AM Staff A, Certified Nursing Assistant (CNA) stated, Oh she goes to the bathroom on her own and really doesn't need our help much. During an interview conducted on 11/8/2023 at 10:45 AM the Director of Nursing (DON) stated, I do see that she has had multiple UTI's. I do not see any training or education to the resident, or that the resident has been assessed for proper cleaning after using the bathroom. I do not see any care plan related to frequent UTI's or that she was at risk for UTI's. We should have a care plan related to her recurrent UTI's due to her history of uterine prolapse. Review of the policy and procedure titled, Care Plans, Comprehensive Person-Centered with a last approval date of 4/26/2023 read, Policy Statement: A comprehensive person centered care plan that includes measurable objectives and timetables to meet the residents physical psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation. Implementation: 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family of legal representative develops and implements a comprehensive, person centered care plan for each resident. 9. Care Plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observation, interview, and record review the facility failed to ensure the necessary care and services to maintain urine flow into a catheter bag was provided and failed to ensure proper infection control techniques for 1 of 2 residents, Resident #87, reviewed for urinary catheter care. Findings include: Review of the admission record for Resident #87 documents diagnoses that include unspecified dementia without behavioral disturbances, essential hypertension, anemia, unspecified protein calorie malnutrition, hyperlipidemia, gastroesophageal reflux disease, obstructive sleep apnea, major depressive disorder, age related osteoporosis, and neurogenic bladder. During an observation conducted on 11/06/23 at 9:16 AM Resident #87 was resting in bed. A urinary catheter bag, without a privacy shield, was visible from the doorway on the left side of the bed. The urinary catheter tubing had loops in the tubing and was touching the floor. The loop of the urinary catheter tubing touching the floor had amber colored urine collected in the tubing that was unable to empty into the urinary catheter drainage bag. During an observation conducted on 11/08/23 at 7:38 AM Resident #87 was resting in bed. A urinary catheter bag was observed outside of the privacy bag. Loops were observed in the catheter tubing and the tip of the port, used to open the system for emptying the urinary catheter drainage bag, was resting on the floor. On the floor were a few drops of yellow urine near the port that was resting on the floor. There was yellow urine that had collected in the tubing that was not able to empty into the urinary catheter drainage bag. Review of the physician orders dated 7/12/2023 read, Suprapubic catheter: Catheter care Q [every] shift and PRN [as needed] every shift for catheter care. Empty drainage bag and provide pericare. Position catheter bag and tubing below the level of the bladder, check tubing is free of kinks and securement device is in place. During an interview conducted on 11/8/2023 at 9:30 AM Staff A, Certified Nursing Assistant stated, All urinary catheter bags should have a privacy shield on and not have loops on the floor. There is urine in the tubing that cannot drain into the bag. During an interview conducted on 11/8/2023 at 9:37 AM Staff B, Licensed Practical Nurse stated, The catheter bag should be in the privacy bag. The patient keeps her bed low that it's hard to have the tubing not loop, the tip of the catheter bag should not be on the floor. During an interview conducted on 11/8/2023 at 11:30 AM the Director of Nursing stated, I expect all staff to maintain any catheters correctly and have them in a privacy shield and they should not touch the floor or have loops in the tubing to promote proper drainage. Review of the policy and procedure titled, Suprapubic Catheter Care, with the last approval date of 4/26/2023 read, General Guidelines: Purpose: The purpose of this procedure is to prevent skin irritation around the stoma and to prevent infection of the resident's urinary tract. 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder. 5. Check the bag frequently to be sure the tubing is free of kinks.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections during direct contact with the residents for medication administration for 2 of 3 nurses observed during medication administration. Findings include: During an observation of medication administration on 5/11/2022 at 7:45 AM, Staff A, Licensed Practical Nurse (LPN), did not perform hand hygiene, poured medications for Resident #14, entered the resident's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident # 14 took the medication cup to her mouth, took the medications, and handed the medication cup back to the Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited Resident #14's room, walked down the hallway, entered the room containing the Pyxis machine, removed a medication, put the medication into a medication cup, returned to Resident #14's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident #14 took the medication, and gave the medication cup to Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited the room, and returned to the medication cart. Staff A did not perform hand hygiene, opened the computer, and began preparing medications for the next resident. During an observation of medication administration on 5/11/2022 at 8:00 AM, Staff B, LPN, did not perform hand hygiene prior to preparing Resident #23's medications. Staff B knocked on the resident's door, entered the resident's room, did not perform hand hygiene, handed the medication cup to the resident. The resident took the cup to his mouth, took the medications, and handed the medication cup back to Staff B. Staff B disposed of the medication cup, did not perform hand hygiene, returned to the medication cart, and began preparing medications for the next resident. During an interview on 5/11/2022 at 8:20 AM, the Director of Nursing (DON) stated it was her expectation that the staff would wash or sanitize their hands prior to preparing or handling a resident's medications. During an interview on 5/11/2022 at 9:00 AM, Staff A, LPN, stated, It is policy to wash or sanitize hands prior to preparing medications and when exiting a resident's room. During an interview on 5/11/2022 at 9:15 AM, Staff B, LPN, stated, It is policy to wash or sanitize our hands before preparing the resident's medications and when entering and exiting a resident's room. Review of the policy and procedure titled, Administering Medications last reviewed on 7/20/2021 read, Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the policy and procedure titled, Handwashing/Hand Hygiene last reviewed on 7/20/2021 read, Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. Before preparing or handling medications.

Based on observation, record review, and interview, the facility failed to implement appropriate plans of action to correct identified quality deficiencies regarding hand hygiene standards of practice during medication administration. Findings include: During an observation of medication administration on 5/11/2022 at 7:45 AM, Staff A, Licensed Practical Nurse (LPN), did not perform hand hygiene, poured medications for Resident #14, entered the resident's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident # 14 took the medication cup to her mouth, took the medications, and handed the medication cup back to the Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited Resident #14's room, walked down the hallway, entered the room containing the Pyxis machine, removed a medication, put the medication into a medication cup, returned to Resident #14's room, did not perform hand hygiene, and handed the medication cup to the resident. Resident #14 took the medication, and gave the medication cup to Staff A. Staff A disposed of the medication cup, did not perform hand hygiene, exited the room, and returned to the medication cart. Staff A did not perform hand hygiene, opened the computer, and began preparing medications for the next resident. During an observation of medication administration on 5/11/2022 at 8:00 AM, Staff B, LPN, did not perform hand hygiene prior to preparing Resident #23's medications. Staff B knocked on the resident's door, entered the resident's room, did not perform hand hygiene, handed the medication cup to the resident. The resident took the cup to his mouth, took the medications, and handed the medication cup back to Staff B. Staff B disposed of the medication cup, did not perform hand hygiene, returned to the medication cart, and began preparing medications for the next resident. During an interview on 5/12/2022 at 10:04 AM, the Administrator stated the facility's Director of Nursing identified a concern regarding hand hygiene and initiated a performance improvement project in September of 2021. A request was made to review the performance improvement plan and all related documentation to verify the implementation of the performance improvement. No performance improvement plan was provided. Review of the Hand Hygiene and Contact Precautions Observations dated 3/4/2022 and 4/19/2022 documented two nurses with no staff identification were observed for hand hygiene during medication administration. No additional documentation was provided. Review of the policy and procedure titled, 2021 Quality Assurance & Performance Improvement (QAPI) Plan, dated 11/21/2017 and reviewed on 7/20/2021 read, The QAPI Steering Committee analyzes performance to identify and follow up on opportunities for improvement (OFI). Ayers Health and Rehabilitation Center continually identifies OFI .Aspects of care occurring most frequently or affecting large numbers of residents.

Based on record review and interview the facility failed to provide nutritional supplements as outlined in the care plan for 1 of 5 residents, Resident #52, sampled for nutritional services in a total sample of 34 residents. Findings: Review of Resident #52's care plan (Revised: 05/15/2020) revealed Resident #52 was at nutritional risk related to endocarditis infection, [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITIONS], diabetes and [MEDICAL CONDITION]. Resident #52's care plan included nutritional interventions that included I am to receive Boost or mighty shake 2 times per day; between meals, (10am and 2pm) to increase caloric intake. Review of Resident #52's medication administration records (Dated: 11/01/2020 - 11/30/2020 and 12/01/2020 - 12/31/20) and treatment administration records (Dated: 11/01/2020 - 11/30/2020 and 12/01/2020 - 12/31/20) failed to reveal documentation Resident #52 had been provided nutritional supplements two times per day; between meals (10am and 2pm) to increase caloric intake as outlined in his care plan as a nutritional intervention. During an interview on 12/16/2020 at 9:05 AM, Staff C (Registered Nurse/Unit Manager) confirmed Resident #52's care plan included a nutritional intervention to be provided nutritional supplements two times per day; between meals (10am and 2pm) to increase caloric intake During interview on 12/16/2020 at 12:03 PM, the facility Registered Dietician stated that she did not believe Resident #52 had been receiving nutritional supplements two times a day as outlined in his care plan as a nutritional intervention. She stated Resident #52 would definitely benefit from the extra calories provided by a nutritional supplement because his intake was poor to moderate and he had a wound issue that increased his nutritional needs.