Every finding on record at Baptist Homes of Arcadia Valley

Based on observation, interview, and record review, the facility failed to ensure staff provided appropriate supervision for a cognitively impaired resident (Resident #1) who was at risk of falling when Certified Nursing Assistant (CNA) A, left the resident unattended in a drained whirlpool tub with the whirlpool door open. The lack of supervision resulted in the resident falling, being airlifted to a hospital where Resident #1 was admitted for four days, having pain, and bruising to the right outer hip. The facility census was 20. Review of the facility's policy titled, Bathing Policy, undated, showed:-Each resident shall have a written personal care plan that includes bathing preferences and any assistance needs;-Residents with cognitive impairments may require enhanced supervision and support. 1. Review of Resident #1's quarterly Minimal Data Sheet (MDS), dated [DATE], showed the resident had severe cognitive impairment, impairment to both upper and lower extremities and required staff assistance for transfers, showers and mobility.Review of Resident #1's medical record showed diagnoses included hemiplegia (a medical condition that causes total paralysis on one side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) following stroke affecting left side, dementia (decline in mental ability severe enough to interfere with daily life, including memory loss, poor judgment, and communication changes) with other behavioral disturbance, generalized anxiety disorder (persistent worry and fear about everyday situations), repeated falls, and disorder of bone density (measures the amount of calcium and minerals in your bones).Review of a Fall Assessment, dated 07/09/26, showed the resident was not oriented to person, place and time, was chairbound and at high risk for falls.Review of an admission Clinical Assessment for Resident #1, dated 08/12/26, showed Resident #1 had severe cognitive impairment which affected all areas of judgement.Review of the August 2026, Physician Order Sheet (POS), showed an order for Tramadol (a pain medication) 25 milligrams (mg) give one tablet by mouth every six hours as needed for pain, dated 03/19/26. Review of August 2026, Medication Administration Record (MAR), showed the Tramadol had only been administered once, on 08/13/26 at 8:18 A.M., after the resident's return from the hospital stay which resulted from the incident.Review of Resident #1's Nurse's notes showed:- On 08/08/26 at 9:15 A.M., Licensed Practical Nurse (LPN) B called to shower room because the resident had fallen out of the whirlpool tub. CNA A bathed the resident, drained the tub, opened the tub door then stepped away. CNA A left the resident in the tub while getting help and the resident fell. Upon entering the shower room, Resident #1 was observed lying next to tub on right side with a small bruise starting on right hip and right lower extremity. Resident dried, dressed, and put into wheelchair with vitals obtained. Assessment forms were completed and all parties were notified of incident. Resident picked up by Emergency Medical Services for evaluation; - On 08/08/26 at 2:24 P.M., staff received information from the hospital that Resident #1 had a fracture to the right pubic ramus (a section of the pubic bone (pubis) in the front of the pelvis). The age of the fracture could not be determined;-On 08/12/26 at 5:55 P.M., Resident #1 arrived back at the facility. Review of the resident's care plan, last updated 08/08/26, showed:-Resident #1 was dependent on staff for all ADL's, including bathing;-Staff were required to anticipate Resident #1's needs and promptly respond to those needs;-Staff were to provide the resident with safety reminders. During an interview on 08/13/26 at 8:00 A.M., the Administrator said, following the incident, CNA A was terminated and sent home. All staff were in serviced on resident safety while bathing. The Administrator said the CNA told her, he/she left the resident in the drained tub because he/she needed to get clothing for Resident #1. During an interview on 08/13/26 at 8:53 A.M., Registered Nurse (RN) C said after finding the resident on the floor outside of the open whirlpool, LPN B and RN C assessed the resident, got the resident dressed, put him/her in a wheelchair and called emergency services. RN C said the assessment showed Resident #1's leg looked turned in, there was a bruise to the right hip and the resident moaned as in pain with movement. RN C said he/she asked the CAN what happened. CNA A said he/she finished bathing the resident in the whirlpool and didn't bring clothes for the resident. CNA A then drained the whirlpool and left the whirlpool door open, told the resident to sit still, and CNA A went to the shower room door to get help to get clothes and heard the resident start screaming. CNA A said when he/she re-entered the whirlpool area the resident was on the floor out of the whirlpool. RN C said the resident's baseline is not being able to make needs fully known and is only oriented to name, but can answer yes/no when asked if he/she is in pain. RN C said, until this incident, the resident did not usually indicate any signs or symptoms of pain. Now the resident moans with most movement. RN C said all staff are trained to gather all needed supplies an be prepared to stay in the shower/bath room until a resident has completed the process. Staff should not leave a resident unattended in the bathtub. During an interview on 08/13/26 at 9:03 A.M., LPN B said he/she was passing medication on 08/08/26. CNA A came out of the shower room to get a nurse. Upon entering the shower room, Resident #1 was on the floor on his/her right side outside of the whirlpool with the whirlpool door open. LPN B asked CNA A what happened to the resident. CAN A told LPN B he/she failed to bring clothes for the resident into the shower room, left the resident in the whirlpool with the door open, and went to the shower room door to ask for help in getting the supplies needed. CNA A said, while standing at the shower room door, the resident started screaming. CNA A turned back into the room and found the resident on the floor beside the whirlpool with the whirlpool door open. LPN B said he/she and RN C noticed a little bruising to the resident's right hip, got the resident up, vitals, and dressed. Cognitive level at the time and currently is oriented to person which is normal. RN C was the charge nurse and made the decision to send the resident to the hospital due to the hip bruising and fall after assessing the resident. The Administrator was notified and CNA A sent home. Staff should take take all supplies needed for a resident to the shower room when showering a resident. Staff should never leave a resident alone in the shower room and use a call light in there if help is needed. During an interview on 08/13/26 at 9:15 A.M., CNA E said he/she helped get Resident #1 up safely into the wheelchair after being found on the shower room floor. CNA E said when he/she walked into the whirlpool area the resident was asked if there was pain. Resident #1 responded by rubbing his/her right hip area where bruising was starting to show. CNA E said Resident #1 has always been anxious during transfers but never expressed pain during the process before this incident. Now the resident moans and shows symptoms of pain with every transfer. CNA E said they are trained to gather all the needed supplies for a shower/bath before starting the process and to never leave a resident unattended in the shower room. During an interview on 08/13/26 at 12:50 P.M., CNA A said that he/she gave the resident a bath in the whirlpool tub on 08/08/26. CNA A said he/she realized he/she did not bring the resident's clothes into the shower room until after the whirlpool tub had been drained. CNA A said he/she stepped away from the tub, leaving the whirlpool door open, left the resident unattended and went to the shower room door. CNA A said he/she stepped into the hall to ask for assistance, when he/she heard screaming. The CNA turned to see Resident #1 screaming, on the floor and outside of the whirlpool with the door still open. CNA A yelled for LPN B. LPN B and CNA A found a bruise to the side of the right hip, got the resident dressed, moved into wheelchair, and sent out to the hospital. CNA A didn't think the resident would move because the resident doesn't usually move. CNA A said he/she should have at least closed the door to the whirlpool or brought all supplies into the shower. During an interview on 08/13/26 at 3:30 P.M., the Administrator and Director of Nursing (DON) said CNA A should not have left the resident alone in the tub and especially with the whirlpool door open. CNA A told them he/she left the resident unattended in the whirlpool with the door open was because he/she forgot to bring clothes for the resident. Education was provided to ensure all supplies should be brought in with the resident for a shower and never leave a resident alone in the shower/bath. The Administrator was notified on 08/13/26 of the Past Non-Compliance which occurred on 08/08/26. On 08/08/26, facility staff started an investigation, completed disciplinary action, and began in-servicing all staff on supervision to prevent accidents. No additional allegations of accidents were found during the on-site investigation. The non-compliance was corrected on 08/08/26. 3146465

Based on observation, interview, record review, and review of facility policy, the facility failed to implement Enhanced Barrier Precautions (EBP - precautions used during high-contact resident care activities for residents infected or colonized with a multidrug-resistant organism (MDRO - microorganisms resistant to one or more classes of antimicrobial agents) or for residents with a chronic wound and/or an indwelling medical device) for three residents (Residents #5, #18, and #30); failed to perform hand hygiene and change gloves between contaminated and clean care activities during resident care for six residents (Residents #5, #8, #9, #18, #27, and #30); and failed to complete and/or maintain required tuberculosis (TB - an infectious bacterial disease that primarily affects the lungs) screening and related documentation for five residents (Residents #5, #8, #11, #18, and #27). These deficient practices created the potential for transmission of infectious organisms among residents, staff, and the environment. The facility census was 29.Review of the facility's policy titled Gloves, dated 2024, showed:- Staff were to don clean, non-sterile gloves in accordance with Standard and Transmission-Based Precautions when anticipating contact with blood, body fluids, secretions, excretions, contaminated items, mucous membranes, or non-intact skin;- Staff were to change gloves between tasks and procedures on the same resident after contact with blood, body fluids, secretions, or excretions;- Staff were to remove gloves promptly after use and before touching clean items or environmental surfaces;- Gloves were not to be worn while caring for more than one resident;- Staff were to perform hand hygiene immediately after glove removal;- Gloves were not to be carried in uniform pockets. Review of the facility's policy titled Hand Hygiene, dated 2024, showed:- Staff were to perform hand hygiene in accordance with accepted standards of practice to reduce the transmission of pathogens;- Hand hygiene was required immediately before resident contact, before handling invasive medical devices, before moving from a contaminated body site to a clean body site on the same resident, after contact with the resident or the resident's environment, after contact with blood or body fluids, and immediately after glove removal;- Gloves and perineal wipes were not substitutes for hand hygiene. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 2024, showed:- Staff were to implement EBP during high-contact resident care activities for residents with wounds, indwelling medical devices, or known MDRO infection or colonization;- High-contact resident care activities included bathing, dressing, transferring, providing hygiene, changing linens or briefs, toileting, wound care, and care of urinary catheters, feeding tubes, central lines, tracheostomies, or ventilators;- Staff were to post EBP signage outside the resident's room;- Staff were to maintain EBP for the duration of the wound or indwelling medical device;- Staff were to provide an isolation cart containing the required personal protective equipment immediately outside the resident's room. Review of the facility's policy titled Tuberculosis Screening - Residents, dated 2024, showed:- Residents were to receive TB screening in accordance with state requirements, including a TB risk assessment, symptom evaluation, and TB testing;- Documentation was to include the date administered, testing method, location, manufacturer, lot number, dose, expiration date, resident response, and staff signature;- A trained nurse was to interpret the test within 48 to 72 hours;- Documentation of the results was to include the date, time, induration measurement in millimeters, presence or absence of adverse effects, and staff signature. Review of the Missouri Department of Health and Senior Services, Division of Community and Public Health, 9 CSR 20-20.100, Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers, effective January 29, 2023, showed all long-term care facility residents were required to receive a documented annual evaluation for signs and symptoms of tuberculosis disease. 1. Observation on 06/16/26 at 8:43 A.M. of incontinent care for Resident #8 showed:- Certified Nursing Assistant (CNA) F and CNA L entered the resident's room, put on gloves, and did not perform hand hygiene;- CNA F propelled the resident in a wheelchair to the bathroom, removed gloves, exited the resident's room, and did not perform hand hygiene;- CNA F reentered the room with washcloths, handed the washcloths to CNA L, exited the room, and did not perform hand hygiene upon entering or exiting the room;- CNA L transferred the resident from the wheelchair to the toilet using a gait belt (a device used to assist with transfers and ambulation);- CNA L lowered the resident's pants and brief, touched the urine-soiled brief, removed the brief, and did not change gloves or perform hand hygiene;- While wearing the same contaminated gloves, CNA L touched the sink faucet, prepared clean washcloths and peri wash (a ready-to-use skin cleanser that does not require rinsing), handled clean supplies, and then provided perineal care without changing gloves or performing hand hygiene;- While wearing the same contaminated gloves, CNA L touched the resident's blanket, assisted the resident to stand, cleansed the resident's buttocks, retrieved a clean washcloth, cleansed the resident's vaginal area from front to back, dried the vaginal area and buttocks with the same washcloth, applied a clean brief, and pulled the resident's pants into place without changing gloves or performing hand hygiene between contaminated and clean care activities;- CNA L removed gloves, assisted the resident back to the wheelchair with bare hands, touched the wheelchair and environmental surfaces, and did not perform hand hygiene until after transporting trash and soiled linens to the soiled utility room. 2. Observation on 06/16/26 at 2:52 P.M. of colostomy care for Resident #18 showed:- No EBP signage was posted outside the resident's room;- The Director of Nursing (DON) entered the resident's room carrying clean scissors, performed hand hygiene, put on gloves, and did not wear a gown while providing high-contact care to a resident requiring Enhanced Barrier Precautions;- The DON placed a clean paper towel on the bedside table, placed the scissors on the paper towel, and completed colostomy (a surgically created opening in the abdomen that allows stool to exit the body) care;- After completing the procedure, the DON removed gloves and did not perform hand hygiene;- Using bare hands, the DON removed the trash bag, transported the trash to the soiled utility room, walked to the treatment cart at the nurses' station, opened the treatment cart drawer, removed and opened an alcohol pad, disinfected the scissors, placed the scissors into a pants pocket, locked the treatment cart, and walked away without performing hand hygiene. During an interview on 06/15/26 at 3:30 P.M., Resident #18 stated staff wore gloves when providing colostomy care but did not wear gowns. 3. Observation on 06/16/26 at 8:51 P.M. of incontinent care for Resident #30 showed:- No EBP signage was posted outside the resident's room;- CNAs B and K entered the resident's room, put on gloves, did not perform hand hygiene, and did not wear gowns while providing high-contact care to a resident requiring Enhanced Barrier Precautions;- Resident #30 remained in bed while CNA K lowered the resident's pants, unfastened the brief, retrieved a clean urinal, assisted the resident with urinal use, emptied and stored the urinal, and did not change gloves or perform hand hygiene;- While wearing the same contaminated gloves, CNA K removed a brief soiled with fecal matter, cleansed the resident's buttocks and gluteal cleft, placed a clean brief under the resident, touched the resident's shirt and bare skin, and secured the clean brief without changing gloves or performing hand hygiene between contaminated and clean care activities;- Both CNAs removed their gloves without performing hand hygiene and immediately transferred the resident to a wheelchair using a Hoyer lift (a mechanical device used to lift and transfer residents);- While wearing contaminated gloves, CNA K touched the Hoyer lift controls and handles, the wheelchair, the resident's eyeglasses, the resident's room door handle, and another resident before performing hand hygiene;- CNA K then returned to Resident #30's room, put on gloves, removed trash and fecal-soiled linens to the soiled utility room, and performed hand hygiene;- CNA B placed socks on the resident, retrieved a blanket from the blanket warmer after leaving the room, returned to make the resident's bed, exited the room, and then performed hand hygiene. 4. Observation on 06/16/26 at 9:13 P.M. of suprapubic catheter care for Resident #5 showed:- No EBP signage was posted outside the resident's room;- Registered Nurse (RN) J gathered supplies, performed hand hygiene, entered the resident's room, placed normal saline in a medication cup on top of the resident's refrigerator, put on gloves, and did not wear a gown while providing catheter care to a resident requiring Enhanced Barrier Precautions;- Resident #5 removed the split gauze from the suprapubic catheter insertion site;- RN J cleansed the catheter insertion site and catheter tubing, removed gloves, and did not perform hand hygiene;- Without performing hand hygiene, RN J removed a permanent marker from a pocket, labeled a clean split gauze dressing, put on clean gloves, applied the split gauze around the catheter insertion site, removed gloves, and again failed to perform hand hygiene;- RN J exited the room, obtained tape from the treatment cart, returned to the resident's room without performing hand hygiene, applied the tape to secure the dressing without gloves, performed hand hygiene, and exited the room. 5. Observation on 06/17/26 at 5:31 A.M. of incontinent care for Resident #9 showed:- CNA C entered the resident's room, did not perform hand hygiene, and put on gloves;- CNA C removed the resident's wet brief, cleansed the resident's groin, rolled the resident, and repeatedly cleansed the resident's buttocks using the same surface of the wipe;- Without changing gloves or performing hand hygiene, CNA C touched the resident's blanket, bed controls, and bedside table;- CNA C removed gloves, transported the trash to the hallway barrel, and then performed hand hygiene. During an interview on 06/17/26 at 5:55 A.M., CNA C stated staff should perform hand hygiene before resident care, change gloves between dirty and clean tasks, and perform hand hygiene at the completion of care. 6. Observation on 06/17/26 at 6:20 A.M. of incontinent care for Resident #27 showed:- CNAs D and E entered the resident's room, did not perform hand hygiene, and put on gloves;- CNA D unfastened the resident's wet brief and cleansed the resident's groin;- Without changing gloves or performing hand hygiene, the CNAs removed the wet brief, placed a clean brief under the resident, pulled the resident's pants into place, transferred the resident from the bed to the wheelchair, and assisted the resident with putting on a clean shirt;-The CNAs removed their gloves and performed hand hygiene at the completion of care. 7. Review of Resident #5's medical record showed:- admission date of 04/29/21;- Documentation showed a Step 1 Tuberculin Skin Test (TST) was administered on 04/27/21 with a negative result of 0 millimeters (mm); however, the record did not include documentation of the test being read;- The medical record did not contain documentation that a Step 2 TST was completed;- The medical record did not contain documentation of the required annual TB screening or evaluation for 2026. 8. Review of Resident #8's medical record showed:- admission date of 09/06/24;- Documentation showed a Step 1 TST administered on 06/06/24 with a negative result of 0 mm; however, the record did not include documentation of the test being read;- Documentation showed a Step 2 TST administered on 05/17/24 with a negative result of 0 mm and read on 05/20/24;- The medical record did not contain documentation of the required annual TB screening or evaluation for 2025. 9. Review of Resident #11's medical record showed:- admission date of 10/09/23;- Documentation showed a Step 1 TST administered on 10/09/23 with a negative result of 0 mm; however, the record did not include documentation of the test being read;- Documentation showed a Step 2 TST administered on 10/19/23 with a negative result of 0 mm. The record documented the test was read on 05/20/24;- The medical record did not contain documentation of the required annual TB screening or evaluation for 2025. 10. Review of Resident #18's medical record showed:- admission date of 07/02/24;- The medical record did not contain documentation of TB screening or testing completed before or upon admission;- The medical record did not contain documentation of the required annual TB screening or evaluation for 2025. 11. Review of Resident #27's medical record showed:- admission date of 02/15/26;- Documentation showed a Step 1 TST administered on 05/27/26 with a negative result of 0 mm; however, the record did not include documentation that the test was read;- Documentation showed a Step 2 TST administered on 06/10/26 with a negative result of 0 mm; however, the record did not include documentation that the test was read. During an interview on 06/16/26 at 4:02 P.M., CNA L stated staff should perform hand hygiene before and after resident care, change gloves and perform hand hygiene when moving from contaminated to clean care activities, and perform hand hygiene after removing gloves. CNA L stated staff should use EBP when caring for residents requiring those precautions. CNA L stated staff should use a clean area of the washcloth for each wipe during incontinent care and wipe from front to back. During an interview on 06/16/26 at 4:02 P.M., CNA F stated residents requiring EBP should have signage posted outside the resident's room identifying the need to wear (PPE), including gowns and gloves. CNA F stated staff had not been provided a list identifying residents requiring EBP. CNA F stated hand hygiene should be performed before and after resident care, after disposing of contaminated items, and when changing from contaminated to clean care activities. CNA F stated staff should use a clean area of the washcloth for each wipe and wipe from front to back during incontinent care. During an interview on 06/16/26 at 10:36 P.M., RN J stated EBP included wearing a gown and gloves when providing care to residents with wounds, urinary catheters, feeding tubes, or peripherally inserted central catheters (PICCs). RN J stated staff should perform hand hygiene before and after resident care and change gloves and perform hand hygiene when moving from contaminated to clean care activities. During an interview on 06/17/26 at 9:29 A.M., the DON stated staff were expected to perform hand hygiene before and after resident care, change gloves and perform hand hygiene when moving from contaminated to clean care activities, use a clean area of the washcloth or a new washcloth for each wipe during incontinent care, and wipe from front to back. The DON stated residents requiring EBP should receive care using the appropriate PPE. The DON further stated the facility expected TB screening and documentation to be completed in accordance with facility policy. The DON acknowledged documentation of TB testing for the identified residents was incomplete and stated the facility would complete TB screening for all residents. During an interview on 06/17/26 at 4:15 P.M., the Administrator stated he expected staff to follow facility infection prevention and control policies, including hand hygiene, glove changes, use of PPE, Enhanced Barrier Precautions, and TB screening requirements.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to with infection surveillance and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 29.Review of the facility's policy titled, Antibiotic Stewardship, dated 2024, showed:- It is the policy that this facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance;- Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes;- The Antibiotic Stewardship Program will be incorporated in the overall infection prevention and control program and reviewed on an annual basis and as needed;- The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria, and compile reports related to monitoring antibiotic usage and resistance data. Review of the facility's policy titled, Infections Surveillance - Overview, dated 2024, showed:- This facility has established a system, based upon national standards of practice and the facility assessment to closely monitor all residents who exhibit signs/symptoms of infection through ongoing surveillance including a systematic method for collecting, analyzing and interpretation of data, followed by dissemination of that information to identify infections, infection risks and outbreaks to those who can improve the outcomes for quality;- The Infection Preventionist will ensure data collection to complete a comprehensive Monthly Infection Control Log for surveillance activities on the infection site, pathogen (if known), signs and symptoms, resident location, summary and analysis of number of residents and/or staff with infections, observations of staff adherence to policies and procedures, identification of outcomes that are unusual or unexpected that could potentially lead to patterns, trends or outbreaks;- The Infection Preventionist will keep an updated map of infections to identify any clusters or trends. Review of the facility's Infection Tracking Folders, dated June 2025 - June 2026, showed:- No documentation of an infection control log for surveillance for June 2025 - October 2025;- No documentation of any map of infections to identify any clusters or trends for June 2025 - October 2025;- No documentation of Infection Tracking Folders provided for November 2025 - June 2026. Review of the facility Matrix (a listing of all facility residents), dated 06/15/26, showed:- Three residents currently received antibiotics;- The facility had no surveillance documentation demonstrating those antibiotic prescriptions had been reviewed through the antibiotic stewardship process. During an interview on 06/17/26 at 9:29 A.M., the Director of Nursing (DON) said she was the Infection Preventionist for the facility and could not locate the antibiotic stewardship surveillance for November 2025 - June 2026. She reviewed the antibiotic stewardship and the surveillance information with the physician monthly and with the department heads weekly. During an interview on 06/17/26 at 4:15 P.M., the Administrator said antibiotic stewardship and surveillance were the DON's responsibility, and he expected all required information to be completed.

Based on observation, interview, and record review, the facility failed to keep one treatment cart locked when left unattended out of two treatment and medication carts. The treatment cart contained prescription creams, powders, and antibiotic capsules. This had the potential to affect all residents. The facility's census was 29. Review of the facility's policy titled, Storage of Medication, dated November 2020, showed:- The facility stores all drugs and biologicals in a safe, secure, and orderly manner;- Drugs and biologicals used in the facility are stored in locked compartments;- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;- Compartments containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 1. Observation of the treatment cart on 06/16/26 at 8:27 A.M., showed:- At 8:27 A.M., the unlocked and unattended treatment cart sat beside the nurse's station and faced the East Hall with no staff in the area and five residents on the side of the nurse's station in wheelchairs;- At 8:31 A.M., Certified Medication Technician (CMT) F walked past the left side of the unlocked and unattended treatment cart;- At 8:32 A.M., the Director of Nursing (DON) walked past the left side of the unlocked and unattended treatment cart;- At 8:33 A.M., a staff member propelled a resident in a wheelchair by the left side of the unlocked and unattended treatment cart;- At 8:34 A.M., the DON walked past the left side of the unlocked and unattended treatment cart;- At 8:36 A.M., the MDS Coordinator walked to the unlocked and unattended treatment cart, locked the cart, and walked away. 2. Observation of the treatment cart on 06/16/26 at 9:23 A.M., showed:- At 9:23 A.M., the unlocked and unattended treatment cart sat beside the nurse's station and faced the East Hall with no staff in the area and four residents on the other side of the nurse's station in wheelchairs;- At 9:26 A.M., CMT F pushed a medication cart to the other side of the nurse's station to administer medications to residents with his/her back turned toward the unlocked and unattended treatment cart; - At 9:26 A.M., a Certified Nursing Assistant (CNA) pulled a bed past the unlocked and unattended treatment cart;- At 9:28 A.M., Licensed Practical Nurse (LPN) H walked toward the unlocked and unattended treatment cart, stopped, and walked past the nurse's station down the hall; - At 9:30 A.M., a CNA walked past the unlocked and unattended treatment cart;- At 9:31 A.M., LPN H walked to the unlocked and unattended treatment cart, opened the top drawer, closed it, and pushed it down the hall. 3. Observation on 06/16/26 at 3:40 P.M., of the treatment cart showed:- At 3:40 P.M., the unlocked and unattended treatment cart sat beside the nurse's station and faced the East Hall with no staff in the area;- At 3:43 P.M., LPN H walked to the unlocked and unattended treatment cart and opened the cart; - At 3:45 P.M., LPN H walked away from the unlocked treatment cart and left it unattended while three residents sat in wheelchairs on the other side of the nurse's station near it; - At 3:55 P.M., LPN H walked up to the unlocked and unattended treatment cart, locked the cart, and walked away. During an interview on 06/17/26 at 12:59 P.M., the Director of Nursing (DON) said staff should lock any treatment or medication cart when left unattended or out of view. During an interview on 06/17/26 at 2:30 P.M., LPN H said any medication or treatment carts should be locked when left unattended. During an interview on 06/17/26 at 4:30 P.M., the Administrator said he would expect staff to keep the treatment and medication carts locked when unattended or not in use.

Based on interview and record review, the facility failed to ensure dialysis (process for removal of waste and excess water from the blood due to kidney failure) communication forms were completed to support ongoing coordination and collaboration of care between facility staff and the dialysis provider for one resident (Resident #5) out of one sampled resident receiving dialysis. The facility's census was 29. Review of the facility's policy titled, Dialysis Care, undated, showed:- Purpose is to adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end-stage renal disease (ESRD - chronic irreversible kidney failure) receiving dialysis;- Did not address ongoing coordination and collaboration between the facility and dialysis. 1. Review of Resident #5's medical record showed:- admission date of 04/29/21;- Diagnoses of ESRD and dependence on renal dialysis. Review of the resident's Dialysis Communication Forms, dated 02/16/26 - 06/18/26, showed:- The dialysis communication forms were not completed for 30 of 30 opportunities;- The medical record did not contain documentation of communication between the dialysis provider and facility staff regarding the resident's dialysis treatment, including treatment completion, pre- and post-dialysis weights, blood pressure readings, fluid removal vascular access assessment, medication or treatment changes, dialysis orders, or complications requiring follow-up care. Review of the resident's physician order sheet (POS), dated June 2026, showed:- An order for dialysis appointment 12:00 P.M. - 4:00 P.M., every Monday, Wednesday and Friday, dated 05/22/24. Review of the resident's care plan, revised 06/10/26, showed:- The need for ongoing dialysis treatment and monitoring. During an interview on 06/17/26 at 10:10 A.M., the resident said he/she sometimes got a communication form when going to dialysis but didn't know what happened to it once he/she got to the dialysis center. During an interview on 06/18/26 at 12:45 P.M., the Director of Nursing (DON) said the nurse sending Resident #5 to dialysis was responsible for completing the dialysis communication form and the receiving nurse was responsible for documenting the information received upon the resident's return. She acknowledged the communication forms were not consistently completed. During an interview on 06/18/26 at 4:30 P.M., the Administrator said staff were expected to ensure dialysis communication forms were completed.

Based on interview and record review, the facility failed to ensure informed consent was obtained and documented before administering psychotropic (a medication that affects brain activities associated with mental processes and behavior) medications for four residents (Residents #3, #6, #21, and #27) out of four sampled residents. This failure prevented the residents and/or their representatives from receiving information regarding the risks, benefits, and alternatives associated with psychotropic medication use before treatment. The facility census was 29. Review of the facility's policy titled, Psychotropic Medication Use, dated July 2022, showed:- Residents will not receive medications that are not clinically indicated to treat a specific condition;- Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes;- Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible;- Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. 1. Review of Resident #3's medical record showed:- admitted on [DATE];- Diagnoses of unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) moderate with psychotic disturbance (a collection of symptoms characterized by a loss of contact with reality), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), myasthenia gravis (MG - chronic neuromuscular disease that causes weakness in the voluntary muscles) without acute exacerbation;- An order for Rexulti (an antipsychotic (psychiatric medications used primarily to manage psychosis - including delusions, hallucinations, paranoia, and disordered thought) medication) 0.5 milligram (mg) by mouth two times a day related to unspecified dementia moderate with psychotic disturbance, dated 01/06/26;- An order for duloxetine (an antidepressant medication) delayed release sprinkle 60 mg by mouth two times a day for anxiety (persistent worry and fear about everyday situations), dated 12/22/25;- No documentation the resident or the resident's representative received education regarding the risks, benefits, and alternatives of the psychotropic medications or provided informed consent before treatment. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Diagnoses of unspecified dementia and sexually aggressive behaviors;- An order for venlafaxine (an antidepressant medication) extended release (ER) 150 mg by mouth one time a day for depression, dated 09/23/25;- An order for Depo-Provera (birth control used as off label for reducing severe compulsive sexual behaviors) 150 mg/milliliter (ml) 1 ml intramuscularly (administer into the muscle) once on the 3rd every three months for sexually aggressive behaviors, dated 10/03/25;- No documentation the resident or the resident's representative received education regarding the risks, benefits, and alternatives of the psychotropic medications or provided informed consent before treatment. 3. Review of Resident #21's medical record showed:- admitted on [DATE];- Diagnoses of major depressive disorder (long-term loss of pleasure or interest in life) and generalized anxiety disorder;- An order for buspirone (an antianxiety medication) 15 mg by mouth three times a day for generalized anxiety disorder, dated 03/24/26;- An order for Remeron (an antidepressant medication) 7.5 mg by mouth one time a day for major depressive disorder, dated 03/11/25;- An order for Abilify (an antipsychotic medication) 5 mg by mouth one time a day for major depressive disorder, dated 03/12/25;- No documentation the resident or the resident's representative received education regarding the risks, benefits, and alternatives of the psychotropic medications or provided informed consent before treatment. 4. Review of Resident #27's medical record showed:- admitted on [DATE];- Diagnoses of unspecified dementia with mood disturbance and anxiety disorder;- An order for sertraline (an antidepressant medication) 50 mg by mouth one time a day for dementia with mood disturbance, dated 03/03/26;- An order for olanzapine (an antipsychotic medication) 5 mg by mouth one time a day for dementia with mood disturbance, dated 03/02/26;- No documentation the resident or the resident's representative received education regarding the risks, benefits, and alternatives of the psychotropic medications or provided informed consent before treatment. During an interview on 06/17/26 at 11:40 A.M., the Director of Nursing (DON) said the psychotropic medication consents were incomplete and were on her list to complete. During an interview on 06/17/26 at 4:30 P.M., the Administrator said the DON had informed him that psychotropic medication consents were needed and acknowledged the facility did not have psychotropic medication consents for residents receiving those medications.

Based on observation, interview and record review, the facility failed to ensure residents' advance directive decisions, including code status, were documented and readily available in the medical record for three residents (Residents #27, #28, and #36) out of 12 sample residents. The facility census was 29. Review of the facility policy titled, Advance Directives, dated [DATE], showed:- Advance care planning - a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions;- Advance directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated;- Prior to or upon admission of a resident, the social services director (SSD) or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives;- If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing it and will document in the medical record the resident's decision;- Information about whether the resident has executed an advance directive is displayed in the medical record in a section of the record that is retrievable by any staff;- If the resident has executed one or more advance directive(s), copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The Director of Nursing (DON) or designee notifies the attending physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care;- The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. 1. Review of Resident #27's medical record showed:- admission date of [DATE];- No advanced directive form in the chart;- No documentation of the resident's code status. - Physician Order Sheet did not reflect the resident's expressed code status. Review of the resident's care plan, initiated [DATE], showed:- Code status not addressed. 2. Review of Resident #28's medical record showed:- admission date of [DATE];- No advanced directive form in the chart;- No documentation of the resident's code status. - Physician Order Sheet did not reflect the resident's expressed code status. Review of the resident's care plan, initiated [DATE], showed:- Code status not addressed. During an interview on [DATE] at 1:58 P.M., Resident #28 said he/she would choose do not resuscitate (DNR) status for the advanced directive and did not want cardiopulmonary resuscitation (CPR - lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped). He/She spoke with the SSD yesterday about his/her advanced directive. 3. Review of Resident #36's medical record showed:- admission date of [DATE];- No advanced directive form in the chart;- No documentation of the resident's code status. - Physician Order Sheet did not reflect the resident's expressed code status. Review of the resident's care plan, dated [DATE], showed:- Code status not addressed. During an interview on [DATE] at 9:22 A.M., Resident #36 said he/she would choose a full code status (all life-saving measures wanted). He/She spoke with the SSD about his/her code status this week. During an interview on [DATE] at 9:07 A.M., Registered Nurse (RN) A said he/she looked in the residents' medical records for a code status. If the code status was not scanned into a resident's electronic medical record (EMR), then he/she considered a resident a full code because of no proof otherwise. During an interview on [DATE] at 4:40 P.M., the Administrator said a resident's code status should be in the chart for every resident. During an interview on [DATE] at 1:57 P.M., the Director of Nursing (DON) and the SSD said the code status documents should be saved in resident's electronic medical record (EMR). The advanced directives should be audited by the nightshift charge nurse or DON within 72 hours of admission or a code status change. When the advanced directive was properly entered as an order in the EMR, it automatically popped up on the face sheet near the top of each resident's face sheet with a link to the document. If it was not in the EMR, it was usually in the resident's file in the front office. That was where the original forms were maintained.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) within the required time frame for one resident (Resident #10) out of nine sampled residents. This failure had the potential to affect the resident's comprehensive assessment and care planning. The facility's census was 29.Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2019, showed:- Assessments be completed and submitted according to federal and state requirements. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- The next comprehensive assessment be completed within 366 days of the previous comprehensive assessment. 1. Review of Resident #10's medical record showed:- admitted on [DATE];- An annual MDS assessment with a completion date of 04/10/25;- A quarterly MDS assessments with completion dates of 07/11/25, 10/11/25, and 01/02/26;- The next annual comprehensive MDS with an ADR date of 04/10/26 and remained In Progress status;- The annual comprehensive MDS assessment was due no later than 04/11/26. The assessment remained In Progress status and was not completed;- The facility did not complete the comprehensive MDS assessment within 366 days of the previous comprehensive assessment as required by the RAI manual. During an interview on 06/18/26 at 3:30 P.M., the Director of Nursing (DON) said she assumed responsibility for completing MDS assessments because the facility did not have an MDS Coordinator. The newly hired MDS Coordinator was employed for two weeks and remained in training. She acknowledged the annual MDS assessment for Resident #10 was not completed within the required time frame. During an interview on 06/18/26 at 4:00 P.M., the Administrator said he expected MDS assessments to be completed within the required time frames.

Based on observation, interview, and record review, the facility failed to ensure staff implemented residents' assessed transfer needs and utilized appropriate transfer techniques and equipment during transfers for two residents (Residents #27 and #30) out of four sampled residents. The facility census was 29.Review of the facility's policy titled, Safe Lifting and Movement of Residents, showed:- In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents;- Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;- Staff will document resident transferring and lifting needs in the care plan;- Staff responsible for direct resident care will be trained in use of manual (gait/transfer belts (device used to transfer residents from one position to another)) and mechanical lifting devices. 1. Observation on 06/17/26 at 6:20 A.M., of Resident #27's two-person transfer from the bed to the wheelchair showed:- Certified Nursing Assistant (CNA) D and CNA E sat the resident up on the side of the bed, did not place a gait belt around the resident's waist, each CNA placed one arm under the resident's right and left underarms, placed the opposite hands on the waist band of the resident's pants, and lifted the resident from the bed by pulling on the resident's pants and underarms while the resident was unable to bear his/her weight;- CNA D and CNA E pivoted the resident and sat him/her in the wheelchair. Review of the resident's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with mood disturbance, anxiety disorder (persistent worry and fear about everyday situations), and chronic pain syndrome. Review of the resident's Lift/Transfer evaluation, dated 03/02/26, showed:- Resident to bear full weight, to be cooperative with transfers, to assist with transfer from bed to chair, and fully assist with repositioning. Review of the resident's care plan, last updated 05/25/26, showed:- Did not address how the resident transferred. 2. Observation on 06/17/26 at 6:40 A.M., of Resident #30's assisted transfer from the wheelchair to the bed showed:- CNA D and Nursing Assistant (NA) G entered the resident's room to transfer the resident from the wheelchair to the bed;- CNA D positioned the resident's wheelchair close to the side of the bed;- NA G told CNA D the resident required a Hoyer lift (a mechanical lift used to transfer residents from one position to another) for transfers. CNA D said he/she wasn't aware the resident now required a Hoyer lift for transfers. NA G said the resident had required a Hoyer lift for transfers for the previous two days. CNA D said he/she was able to lift the resident without difficulty and proceeded with the transfer;- CNA D did not place a gait belt around the resident's waist, placed his/her hands under the resident's underarms, the resident looped his/her hands around CNA D's neck, CNA D lifted the resident up out of the wheelchair while the resident was unable to bear his/her own weight, pivoted, and sat the resident on the side of the bed. Review of the resident's medical record showed:- admission date of 09/18/25;- Diagnoses of chronic diastolic heart failure (impaired heart function), acquired absence of other right toe (amputation of right toe), and glaucoma (a disease affecting eye pressure and causing gradual loss of vision);- An order for a Hoyer lift for all transfers, dated 06/11/26. Review of the resident's Lift/Transfer evaluation, dated 09/18/25, showed:- Resident can bear partial weight, right side dominant/stronger side, cooperative with transfers and repositioning, can assist with transfers from bed to chair, can partially assist with repositioning in bed and chair. Review of the resident's care plan, last revised 06/03/26, showed:- Did not address how the resident transferred. During an interview on 06/17/26 at 6:42 A.M., CNA D said he/she was not aware of the downgrade of Resident #30's mobility for transfers. A resident's method of transfer should be found in their orders and care plan. He/she did not think CNAs could see the orders for the residents but could have looked at the care plan. During an interview on 06/18/26 at 12:49 P.M., the Director of Nursing (DON) said staff should always use a gait belt if doing a transfer without a mechanical lift. CNAs have access to the care plans and Kardex (a quick-reference data system to track essential resident information) which should include each resident's individual transfer needs. If not, they should ask a nurse or therapy before transferring a resident. During an interview on 06/18/26 at 4:30 P.M., the Administrator said he would expect staff to safely transfer residents which would include using a gait belt or the type of mechanical lift required to safely transfer a resident.

Based on interview and record review, the facility failed to timely complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment within 14 days of admission to hospice services for two residents (Residents #1 and #30) out of two sampled residents. The facility census was 39.Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised July 2017, showed:- Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual, dated October 2025, showed:- A significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election. A significant change in status assessment must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. 1. Review of Resident #1's medical record showed:- admitted to hospice on 08/28/25;- No completed significant change MDS dated on or after 08/28/25;- No Significant Change MDS within 14 days following hospice election. 2. Review of Resident #30's medical record showed:- admitted to hospice on 05/20/26;- No completed significant change MDS dated on or after 05/20/26;- No Significant Change MDS within 14 days following hospice election. During an interview on 06/17/26 at 2:30 P.M., the Director of Nursing (DON) said she was responsible for the completion of the MDS assessments due to not having an MDS Coordinator. A new MDS Coordinator was hired two weeks ago and was still in training. She expects MDS assessments, including a significant change assessment, to be completed and submitted on time. If a resident was admitted or discharged from hospice care, she would expect a significant change MDS to be completed and submitted within 14 days. During an interview on 06/17/26 at 4:15 P.M., the Administrator said he would expect a significant change MDS to be completed on time and in the appropriate timeframe.

Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments within the required time frames for six residents (Residents #2, #7, #9, #16, #22, and #29) out of 12 sampled residents. This failure had the potential to affect the residents' comprehensive assessments and care planning. The facility's census was 29.Review of the facility's policy titled, MDS Completion and Submission Timeframes, dated July 2019, showed:- Assessments be completed and submitted according to federal and state requirements. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- Quarterly assessments are due within 92 days of the previous Omnibus Budget Reconciliation Act (OBRA - Nursing Home Reform Act of 1987, which improved the quality of care in nursing homes by setting federal standards of how care should be provided to residents) assessment's assessment reference date (ARD);- The MDS completion date must be within 14 days after the ARD. 1. Review of Resident #2's medical record showed:- admitted on [DATE];- The previous quarterly MDS assessment was completed on 01/07/26;- The next quarterly MDS assessment had an ARD of 04/09/26, a completion due date of 04/23/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. 2. Review of Resident #7's medical record showed:- admitted on [DATE];- The previous quarterly MDS assessment was completed on 02/13/26;- The next quarterly MDS assessment had an ARD of 05/16/26, a completion due date of 05/30/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. 3. Review of Resident #9's medical record showed:- admitted on [DATE];- The previous annual MDS assessment was completed on 01/30/26;- The next quarterly MDS assessment had an ARD of 05/01/26, a completion due date of 05/15/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. 4. Review of Resident #16's medical record showed:- admitted on [DATE];- The previous quarterly MDS assessment was completed on 01/21/26;- The next quarterly MDS assessment had an ARD of 04/23/26, a completion due date of 05/07/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. 5. Review of Resident #22's medical record showed:- admitted on [DATE];- The previous quarterly MDS assessment was completed on 02/02/26;- The next quarterly MDS assessment had an ARD of 05/05/26, a completion due date of 05/19/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. 6. Review of Resident #29's medical record showed:- admitted on [DATE];- The previous admission MDS assessment was completed on 01/25/26;- The next quarterly MDS assessment had an ARD of 04/27/26, a completion due date of 05/11/26, and remained incomplete and unsubmitted;- The facility did not complete the quarterly MDS assessment within the required time frame. During an interview on 06/18/26 at 3:30 P.M., the Director of Nursing (DON) said she assumed responsibility for completing MDS assessments because the facility did not have an MDS Coordinator. A new MDS Coordinator was employed for two weeks and remained in training. She acknowledged the quarterly MDS assessments for Residents #2, #7, #9, #16, #22, and #29 were not completed within the required time frames. During an interview on 06/18/26 at 4:00 P.M., the Administrator said he expected MDS assessments to be completed within the required time frames.

Based on interview and record review, the facility failed to provide required written transfer and discharge information, including complete bed-hold notices and required advocacy agency contact information for hospital transfers and notify the Office of the State Long-Term Care Ombudsman of resident transfers or discharges for five residents (Residents #4, #5, #11, #18, and #33). The facility also failed to provide a discharge summary that included a recapitulation of the resident's stay for one resident (Resident #35) out of one sampled resident discharged to the community. The facility census was 29.The facility did not provide a policy for addressing transfer/discharge notices, bed-hold notices, notification of the Office of the State Long-Term Care Ombudman or required advocacy agency contact information. Review of the facility policy titled, Discharge Summary and Plan, revised October 2022, showed:- When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge;- The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 1. Review of Resident #4's medical record showed:- Transferred to the hospital on [DATE] and 06/01/26;- No documentation the resident or the resident representative received written transfer/discharge notices that included the reason for the transfer, and the required Office of the State Long-Term Care Ombudsman contact information, or the required Protection and Advocacy agency contact information;- No documentation the facility notified the office of the State Long-Term Care Ombudsman after transfer/discharge. 2. Review of Resident #5's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and 05/23/26;- No documentation the resident or the resident representative received a written transfer/discharge notice that included the reason for the transfer, and the required Office of the State Long-Term Care Ombudsman contact information or the required Protection and Advocacy agency contact information on 05/06/26. Review of the resident's Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 05/23/26, showed:- Did not include the daily bed-hold rate, and the required Office of the State Long-Term Care Ombudsman contact information, or the required Protection and Advocacy agency contact information;- No documentation the facility notified the office of the State Long-Term Care Ombudsman after transfer/discharge. 3. Review of Resident #11's medical record showed:- Transferred to the hospital on [DATE], 05/13/26, and 05/29/26;- No documentation the resident or the resident representative received a written transfer/discharge notice that included the reason for the transfer, and the required Office of the State Long-Term Care Ombudsman contact information or the required Protection and Advocacy agency contact information on 04/29/26, 05/13/26, and 05/29/26;- No documentation the facility notified the office of the State Long-Term Care Ombudsman after transfer/discharge. Review of the resident's Bed-Hold and Return Notification forms, dated 04/29/26, 05/13/26, and 05/29/26, showed:- Did not include the daily bed-hold rate. 4. Review of Resident #18's medical record showed:-Transferred to the hospital on [DATE], 03/16/26, 04/05/26, 04/23/26, and 06/08/26;- No documentation the resident or the resident representative received written transfer/discharge notices that included the reason for the transfer, and the required Office of the State Long-Term Care Ombudsman contact information, or the required Protection and Advocacy agency contact information;- No documentation the facility notified the office of the State Long-Term Care Ombudsman after transfer/discharge. 5. Review of Resident #33's medical record showed:- Transferred to the hospital on [DATE];- No documentation the resident or the resident representative received a written transfer/discharge notice that included the reason for the transfer, and the required Office of the State Long-Term Care Ombudsman contact information or the required Protection and Advocacy agency contact information;- No documentation the facility notified the office of the State Long-Term Care Ombudsman after transfer/discharge. Review of the resident's Bed-Hold and Return Notification forms, dated 04/09/26, 05/13/26, and 05/29/26, showed:- Did not include the daily bed-hold rate. 6. Review of Resident #35's medical record showed:- admitted on [DATE];- discharged home on [DATE]; - Did not contain documentation the resident and/or the resident's representative received a discharge summary that included a recapitulation of the resident's stay. During an interview on 06/17/26 at 4:15 P.M., the Administrator said staff were responsible for completing transfer/discharge notices, bed-hold notices, and required notification when residents transferred or discharged from the facility. During an interview on 06/25/26 at 1:57 P.M., the Director of Nursing and the Social Services Designee said when a resident was discharged , a transfer form was initiated prior to the resident leaving, and it was explained to the resident where they understood where and why they were leaving. The residents should receive the transfer/discharge and bed-hold forms, along with the information of the daily bed-hold rate, the appeals process, and the Ombudsman contact information.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plans that reflected residents' current diagnoses, physician orders, and care needs through measurable, resident-specific interventions for two residents (Residents #3 and #30) out of 16 sampled residents. The facility census was 29.The facility did not provide a care plan policy. Review of Resident #3's medical record showed:- admitted on [DATE];- Diagnoses of Myasthenia gravis (chronic neuromuscular disease that causes weakness in the voluntary muscles) without (acute) exacerbation, Heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), Atrial fibrillation (heart dysrhythmia), personal history of other venous thrombosis (when a blood clot blocks a vein) and embolism (blockage of a blood vessel), polyneuropathy (a condition in which a person's peripheral nerves are damaged), gastroesophageal reflux disease (GERD, stomach contents leak backwards into the esophagus). Peptic ulcer (open sores in your stomach lining), stress incontinence (leakage of urine during moments of physical activity that increases abdominal pressure), unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), moderate with psychotic disturbance (a collection of symptoms characterized by a loss of contact with reality);- An order for Donepezil (a medication used to treat dementia) HCI oral tablet 5 milligrams (mg), give 1 tablet by mouth one time a day related to unspecified dementia, moderate, with psychotic disturbance, dated 03/30/26;- An order for Duloxetine (an antidepressant medication) HCI oral capsule delayed release sprinkle 60 mg, give 60 mg by mouth two times a day for anxiety, dated 12/22/25;- An order for Esomeprazole Magnesium (a medication used to treat heartburn, GERD, and ulcers) capsule delayed release 40 mg, give 1 capsule by mouth one time a day for GERD, dated 09/18/25;- An order for Furosemide (a diuretic medication) oral tablet 20 mg, give 1 tablet by mouth one time a day for bilateral lower extremity (BLE) edema, dated 01/15/26;- An order for Namenda (a medication used to treat dementia) oral tablet 10 mg, give 1 tablet by mouth two times a day related to unspecified dementia, moderate, with psychotic disturbance, dated 01/06/26;- An order for Rexulti (an antipsychotic (psychiatric medications used primarily to manage psychosis - including delusions, hallucinations, paranoia, and disordered thought) medication) oral tablet 0.5 mg, give 1 tablet by mouth two times a day related to unspecified Dementia, moderate, with psychotic disturbance, dated 01/16/26;- An order for Xarelto (a blood-thinner medication) oral tablet 20 mg, give 1 tablet by mouth one time a day for a-fib, dated 09/18/25. Review of the resident's care plan, last revised 06/11/26, showed:- Did not address dementia with psychotic disturbances, Myasthenia gravis, heart failure, a-fib, GERD, peptic ulcer, and stress incontinence;- Did not address Donepezil, Duloxetine, Furosemide, Namenda, Rexulti, and Xarelto with person-centered interventions. Review of Resident #30's medical record showed:- admitted on [DATE];- Diagnoses of chronic diastolic (congestive) heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), malignant neoplasm of the prostate (cancer of the prostate) , acquired absence (surgical removal) of other right toe, unspecified, unspecified glaucoma (diseases that cause eye pressure to increase, leading to permanent vision loss);- An order for Morphine (an opioid medication used to treat pain) Sulfate (Concentrate) Solution 20 MG/ML, give 0.5 ml by mouth every 2 hours as needed for pain, dated 06/12/26;- An order for Hydrocodone-Acetaminophen (a narcotic pain medication used to treat moderate to severe pain) oral tablet, give 2 tablet by mouth every 6 hours for pain, dated 06/12/26;- An order to use a HOYER LIFT (a mechanical device used to move or transfer a person) (is a mobile floor lift system that rolls on wheels and is intended to help lift, suspend and transfer a medically dependent person from a bed, toilet, bathtub, shower or a wheelchair) for all transfers, dated 06/11/26;- An order for Apply heel protector (a protective device used for pressure relief on heels) to left foot while in bed every day and night shift for wound, dated 03/19/2026;- An order for Left foot just below the fifth digit: Cleanse wound with wound cleanser, apply skin prep (a protective barrier wipe) to peri wound, apply topical antibiotic (CMP VANC 130MG: mix 1 capsule with up to 6 pumps of [NAME]-gel) to wound bed, then apply hydrofera blue (an antibacterial wound dressing) ready transfer, and cover with vetuvit (a non-bordered superabsorbent dressing). Every day shift for wound, dated 04/08/26;- An order to Cleanse area to Right outer forearm with normal saline (NS) or wound cleanser. Apply xerofoam (a sterile, non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petrolatum blend)/Vaseline gauze. Cover with dry dressing. Wrap with kerlix (gauze bandage roll). Change daily and prn (as needed) if becomes soiled or removed. one time a day forwound to right arm AND as needed for wound to right arm, dated 06/04/26. Review of the resident's care plan, revised 05/21/26, showed:- Did not address Morphine, and hydrocodone-acetaminophen with person-centered interventions;- Did not address the resident's left foot and right forearm wounds with person-centered interventions;- Did not address mobility limitations with person-centered interventions;- Did not address the use of a mechanical lift for transfers. During an interview on 06/17/26 at 12:29 P.M., the Director of Nursing said care plans should be individualized to reflect each resident. Care plans should be updated when there is a change in orders or a resident's condition. During an interview on 06/17/26 at 4:15 P.M., the Administrator stated care plan should be completed timely, individualize them, and revise them as needed.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. The facility census was 29.Review of the facility's policy titled, Homelike Environment, revised February 2021, showed:- Residents are provided with a safe, clean, comfortable and home-like environment and encouraged to use their personal belongings to the extent possible;- Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences;- The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. Review of the facility's policy titled, Infection Prevention and Control Manual Environmental Services/Housekeeping/Laundry, dated 2024, showed:- Surfaces such as tabletops, window ledges, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors, and all other surfaces will be cleaned daily using the appropriate EPA-registered approved hospital grade disinfectants;- These surfaces will also be cleaned (and disinfected) as needed when spills or soiling occur. 1. Observation on 06/16/26 at 3:08 P.M., of the men's shower room showed:- Shower stall interior corner with an approximate 3 foot (ft.) by 4 ft. section of white ceramic tiles had a build-up of a black substance below the grab rail on the right side near the floor;- The majority of the shower stall floor with brown ceramic tiles had a build-up of a white substance;- The bench seat with an approximate 2 ft. by 2 inch (in.) non-intact Formica edge. 2. Observation of 06/16/26 at 3:18 P.M., of the women's shower room showed:- The shower stall wall left of the faucet handle with two missing 4 in. by 4 in. ceramic tiles;- The right-side shower stall wall near the floor with a missing outside corner tile and a non-intact ceramic baseboard section;- A 12 in. by 8 in. section of lavender ceramic tiles with a build-up of a black substance below the toilet near the floor;- The ceiling area near two 2 ft. by 2 ft. Heating Ventilation and Air conditioning (HVAC) vents with six 3 in. diameter sections of peeled paint. During an interview on 06/17/26 at 4:38 P.M., the Housekeeping Supervisor said the showers should be cleaned and disinfected every day. The Certified Nursing Assistants (CNAs) did the inside of the tubs, but housekeeping did the rest. Strippers were used on the vinyl floor tiles in the hall, and a disinfectant was used on the walls. The mold and mildew should be mold and mildew free. There were missing ceramic tiles. When the showers were cleaned, staff were supposed to tell the supervisor if it hadn't been cleaned good enough. Staff had not reported the concerns. The floors and walls were stripped approximately one to one and one-half months ago. 3. Observation on 06/16/26 at 3:25 P.M., of the nurse's station and the common area showed:- A blue chair with a 4 in. by 1 in. non-intact vinyl section of the backrest and three 4 in. by 1 in. non-intact sections of the seat's front edge. 4. Observation on 06/17/26 at 5:45 A.M., of room [ROOM NUMBER] showed:- An approximate 1-in. gap between the HVAC unit and the wall which allowed visible daylight from the outside to enter the resident room. 5. Observation on 06/17/26 at 5:54 A.M., of room [ROOM NUMBER] showed:- A non-intact 2 ft. section of vinyl cove baseboard peeled from the wall section to the left of the HVAC unit;- An approximate 1-in. gap between the HVAC unit and the wall which allowed visible daylight from the outside to enter the resident room. 6. Observation on 06/17/26 at 5:59 A.M., of room [ROOM NUMBER] showed:- A 4 ft. lavatory sink with a clogged drain;- A 6 ft. wall area near the lavatory with a 4 ft. by 2 ft. section of peeled paint near the floor;- An approximate 1-in. gap between the two HVAC units and the wall which allowed visible daylight from the outside to enter the resident room;- An L-shaped ceiling tile lay above the ceiling, outside of the metal frame. During an interview on 06/17/26 at 6:00 A.M., the resident in room [ROOM NUMBER] said the soap was usually empty in the shower and there was mold on the wall. The sink did not drain and may be clogged or in need of venting. There was an unsealed gap around the HVAC units, it had allowed bugs in the room in the past. He/She spoke with staff about the concerns, and it was frustrating. During an interview on 06/17/26 at 1:48 P.M., Maintenance Assistant M said any repairs went into their computer system. He/She was made aware of concerns by the supervisor about whether there were repairs needed in the building. The showers and air conditioners should be maintained. There should not be gaps that could allow pests or air infiltration inside the building. Residents could report concerns to any staff, and the concerns could be entered into the computer system. During an interview on 06/17/26 at 4:36 P.M., the Administrator said there should not be an air gap between the HVAC units and the wall. The paint on the walls and ceilings should be intact in the resident areas of the facility. The showers should be cleaned daily and should not have signs of mold or mildew.

Based on interview and record review, the facility failed to develop a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 25. Review showed the facility did not have a QAPI plan containing the necessary policies and protocols describing how they will identify and correct their quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurement. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said she just started in January 2025, and found no documentation of a previous QAPI Plan. She was trying to get everything together but did not have anything in place yet.

Based on interview and record review, the facility failed to maintain quarterly Quality Assurance and Improvement Program (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 25. The facility did not provide a policy or any documentation related to QAPI. Review showed no documentation the facility maintained the minimum required quarterly QAA meetings with the required members. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said the facility did not have a QAPI policy and procedure. There was not a QA committee at this time. There was no documentation to review.

Based on interview and record review, the facility failed to ensure the Quality Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 25. The facility did not provide a policy for a QAPI Plan or Performance Improvement Plans (PIPs). Review showed no documentation the facility maintained the minimum required documentation for a QAPI plan or PIPs. During an interview on 03/07/25 at 9:11 A.M., the Director of Nursing (DON) said there was no documentation the facility had a QAPI Plan or PIPs in place. The facility was currently trying to get everything in place.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (ICIP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 25. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program; - The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed: - Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; - As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP) or designee; - The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; - At the conclusion of the review, the provider will be notified of the review findings; - All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include resident name and medical record number; unit and room number; date symptoms appeared; name of antibiotic; start date of antibiotic; pathogen identified; site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. The facility did not provide documentation for the Antibiotic Stewardship Program. Review of the facility's Antibiotics Report, from 02/01/25 To 03/31/25, showed: - Eight residents received antibiotics. Review of the facility's Matrix (a listing of all facility residents), dated 03/04/25, showed: - Two residents currently received antibiotics. During an interview on 03/04/25 at 12:35 P.M., the Director of Nursing (DON) said they were working on getting the Infection Control program up and running, but it was not fully in operation yet. The facility's pharmacy consultant company completed an antibiotic report monthly, but the facility did not do their own infection surveillance.

Based on observation, interview, and record review, the facility staff failed to maintain appropriate infection control practices by not performing proper hand hygiene and glove changing techniques during wound care for two residents (Residents #5 and 13) out of two sampled residents and during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #13) out of two sampled residents. The facility also failed to correctly screen five residents (Residents #4, #8, #13, #17, and #20) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility census was 25. The facility did not provide an infection control policy. Review of the facility policy titled, Catheter Care, Urinary, revised September 2014, showed: - The purpose of this procedure is to prevent catheter-associated urinary tract infections; - Place the clean equipment on the bedside stand or overbed table; - Wash and dry your hands thoroughly; - Put on gloves; - Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward; - Secure catheter utilizing a leg band; - Remove gloves and discard into designated container. Wash and dry your hands thoroughly; - Reposition linens, make resident comfortable; - Clean area and discard items; - Wash and dry your hands thoroughly. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, showed: - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; before preparing or handling medications; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin; after handling used dressings, contaminated equipment, etc.; after removing gloves; and is the final step after removing and disposing of personal protective equipment (PPE). Review of the facility policy titled, Enhanced Barrier Precautions (EBP), dated August 2022, showed: - EBPs are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; - Gloves and gown are applied prior to performing high contact resident care activity; - PPE is changed before caring for another resident; - Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter), and wound care (any skin opening requiring a dressing); - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; - Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required; - PPE is available outside of the resident rooms. Review of the facility policy titled, TB, Screening Residents for, revised August 2019, showed: - This facility shall screen all residents for TB infection and disease; - The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB; - Screening of new admissions or readmissions for tuberculosis infection and disease is in compliance with state regulations; - The facility will conduct an annual risk assessment to determine risk of exposure; - Residents who have risk factors for exposure to active TB are re-tested for latent tuberculosis infection (LTBI) and symptoms of active TB. 1. Observation on 03/05/25 at 10:28 A.M., of Resident 313's catheter care showed: - No EBP signage on or around the door; - Certified Nursing Assistant (CNA) F and CNA G entered the room, performed hand hygiene, put on gloves, and did not put on gowns; - CNA F uncovered the resident, unfastened the top of the brief, and sat the wipes beside the resident on the bed without a clean barrier; - CNA F wiped toward the insertion point of the catheter twice with the same area of the wipe; - CNA F failed to wipe away from the insertion point and failed to use a clean wipe or clean side of the wipe with each cleaning motion; - CNA F removed the gloves and failed to perform hand hygiene. 2. Observation on 03/05/25 at 1:45 P.M., of Resident #13's wound care showed: - No EBP signage for the resident; - Registered Nurse (RN) A gathered supplies, performed hand hygiene, entered the room, put on gloves, and did not put on a gown; - The resident sat on the toilet in the bathroom with CNA F and CNA G assisting the resident to stand using a sit-to-stand lift (a device that assist individuals with limited mobility to transition from a seated to a standing position). CNA F and CNA G had gloves on, did not wear gowns, and rolled the resident out of bathroom into the room; - RN A cleaned the wound to left buttock with Dermaklenz (a wound cleanser) and gauze, changed the glove on the right hand, did not perform hand hygiene, applied Triad Paste (a wound treatment) to the left buttock, covered with a 2 inch (in.) x 2 in. silicone foam dressing (type of dressing), removed the gloves, exited the room, and performed hand hygiene; - CNA G pulled the resident's pants up and assisted CNA F to transfer the resident to the recliner; - CNA G hung the resident's Foley (type of catheter) catheter drainage bag covered by a privacy bag on the outside of the trash can by the recliner; - CNA F and CNA G removed the gloves, exited the room, and performed hand hygiene. 3. Observation on 03/05/25 at 2:05 P.M., of Resident #5's wound care showed: - No EBP signage for the resident; - RN A entered the room with the supplies, washed hands, put on gloves, did not put on gown, opened the gauze package, sprayed Dermaklenz on the gauze, touched the resident's clothing to expose the wound area to left upper thigh, removed the gloves, discarded the gauze, did not perform hand hygiene, and exited the room; - CNA F and CNA G entered the room, put on gloves, did not perform hand hygiene, did not put on a gown, and assisted the resident to roll to the right side; - RN A performed hand hygiene, put on gloves, did not put on a gown, sprayed Dermaklenze on the wound area, wiped with a dry gauze, did not change gloves, did not perform hand hygiene, applied Silvadene cream 1% (a topical antibacterial used to prevent or treat wound infection in second and third-degree burns) to the wound, removed the gloves, did not perform hand hygiene, touched the bed control, the oxygen tubing, the pillow, the call light, and the incontinent pad to reposition the resident in bed, performed hand hygiene, and exited the room; - CNA G assisted the resident to reposition in bed, removed the gloves, performed hand hygiene, and exited the room; - CNA F removed the gloves, performed hand hygiene, placed a pillow under the resident's feet, touched the sheet, performed hand hygiene, and exited the room. 4. Review of Resident #4's medical record showed: - admit date of 10/10/12; - Annual TB screen, dated 10/11/23; - No annual tuberculin skin test (TST) or screening completed for 2024. 5. Review of Resident #8's medical record showed: - admit date of 12/19/22; - Annual TB screen, dated 06/07/24, negative 0 millimeter (mm) with no read date. 6. Review of Resident #13's medical record showed: - admit date of 04/26/24; - TST step one, dated 05/06/24, with negative 0 mm and no read date; - TST step two, dated 05/11/24, with negative 0 mm and no read date. 7. Review of Resident #17's medical record showed: - admit date of 07/02/24; - No documentation of TST or screening completed. 8. Review of Resident #20's medical record showed: - admit date of 09/06/24; - TST step one, dated 05/06/24, with negative 0 mm and no read date; - TST step one, dated 05/17/24, with negative 0 mm and no read date. During an interview on 03/06/25 at 4:15 P.M., RN A said EBP, gown and gloves should be worn when providing care for residents with indwelling catheters, MDRO infection risks, wounds, or any other open areas. He/She should have worn a gown while performing wound care. Gowns and gloves were available all the time, and he/she knew where to locate them. Hand hygiene should be completed before, between, and after resident care. Gloves should be changed and hand hygiene should be preformed when moving from a dirty to a clean task. Catheter care should be performed by using a clean wipe to clean the catheter from the insertion point out, fold the wipe to a new area with each swipe, no back-and-forth motion, and cleaning six to eight inches down the catheter. During an interview on 03/06/25 at 4:31 P.M., CNA F and CNA G said should perform hand hygiene and put on gloves for resident care. Catheter care should be completed by cleaning from the insertion point to six to eight inches down the catheter, using a new wipe each swipe for peri care and catheter care. Should change gloves and perform hand hygiene when moving to a new area, before applying barrier cream, and before placing a new brief or touching anything clean. CNA F and CNA G did not know about EBP for the residents. During an interview on 03/07/25 at 11:08 A.M., RN E said EBP should be initiated for a resident with an indwelling device, MDRO, and/or a chronic wound. Staff and the resident should be notified. There were door hangers to hold supplies, with signs for the door, and additional PPE in the clinic and staff have access to the clinic. While in the room and during high contact activities, staff will gown and glove. A gown and gloves should be worn during catheter care and wound care. For catheter care, should clean from the insertion point down several inches. After all care was done, make sure the resident was covered and wash hands. Hand hygiene should be completed anytime gloves were soiled or moving from dirty to clean care, and upon entering and exiting the rooms. TB TST or assessments should be done on admission, during an outbreak, and annually. The TST step two should be completed two-three weeks following the TST step one and both should be read 24-72 hours after testing. The admitting nurse was responsible for completing the TB testing. He/She guessed he/she was responsible for the monitoring. During an interview on 03/07/35 at 11:15 A.M., the Director of Nursing (DON) said EBP, gowns, and gloves should be worn during care of a resident if there were wounds, infections, and anytime care was performed, for residents with catheters and/or wounds. For catheter care, should clean from the insertion point down several inches, using a clean area of the wipe or a new wipe each swipe. Hand hygiene should be completed anytime gloves were soiled, moving from dirty to clean care, and upon entering and exiting rooms. TB testing should be completed upon admission, during an outbreak, and annually. The second step TST was to be completed two-three weeks following the first step TST. Both TST steps should be read 24-72 hours after testing.

Based on interview and record review, the facility failed to provide documentation of communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #2) out of one sampled resident. The facility census was 25. Review of the facility's policy titled, Dialysis Care, undated, showed: - Adequately assess resident needs and provide care goals which achieve the highest practicable level of care to residents with end stage renal disease receiving dialysis; - Risk factors related to potential for bleeding, alterations in fluid volume, potential for infection, alteration in nutrition, skin integrity, risk for adverse medication effects and psychosocial needs should be identified, assessed and interventions to manage addressed in the individualized care plan; - An individual care plan should be developed and followed in coordination with the comprehensive assessment. 1. Review of Resident #2's Physician's Order Sheet (POS), dated March 2025, showed: - admitted on [DATE]; - Diagnosis of end-stage renal disease (ESRD - a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood); - An order for dialysis one time a day, every Monday, Wednesday and Friday, dated 05/21/24; - An order to assess the dialysis site for bleeding or signs or symptoms of infection every shift, dated 05/21/24; - An order to check the dialysis site for a thrill (a palpable vibration felt on the skin over a blood vessel) and the bruit (an audible sound heard through a stethoscope) every shift, dated 05/21/24. Review of the resident's quarterly Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 12/18/24, showed: - The resident received dialysis. Review of the resident's Care Plan, dated 12/30/24, showed: - The resident needs dialysis related to renal failure; - Do not take a blood pressure or draw blood from the arm with the fistula (a connection between an artery and a vein used for dialysis); - Monitor labs and report to the physician as needed; - Encourage the resident to go to scheduled dialysis appointments every Monday, Wednesday and Friday; - Monitor, document, and report as needed any signs and symptoms for infection to the access site, any signs and symptoms of bleeding. Review of the resident's medical record showed: - No Dialysis Communication Reports between the facility and the dialysis unit. During an interview on 03/07/25 at 09:11 A.M., the Director of Nursing (DON) said the facility should be sending a form to the dialysis unit with the resident's information and the dialysis facility should be filling out the dialysis portion and returning it to the facility with the resident. This was not being done. During an interview on 03/07/25 at 10:28 A.M., Registered Nurse (RN) A said he/she had not used a dialysis communication sheet at this facility.