Every finding on record at Bayside Care Center

Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for two resident (#7 and #83) out of four residents sampled for medication administration. This resulted in 3 errors out of 28 medication administration opportunities for a medication error rate of 10.71%.Findings included:1.) An observation was conducted on 3/17/2026 at 9:30 AM of medication administration with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN was observed preparing and administering the following medications for Resident #7:Cholecalciferol Capsule 25 mcg (microgram) / 1000 units x 1 tabletCranberry Oral Tablet 450 mg (milligram) x 1 tablet Reconciliation of Resident #7's physician orders showed the following orders:Cholecalciferol Capsule 400 UNIT - Give 1 capsule by mouth one time a day for Vitamin D deficiency.Cranberry Oral Tablet 400 MG (Cranberry (Vaccinium macrocarpon)) Give 1 tablet by mouth two times a day for UTI ppx (prophylaxis).An interview was conducted on 3/17/2026 at 9:39 AM with Staff A, LPN. Staff A, LPN said she did not realize the medications were the wrong doses. Staff A, LPN said she should have double checked the bottles before administering the medications.2.) An observation was conducted on 3/17/2026 at 9:12 AM of medication administration with Staff F, LPN. Staff F, LPN was observed preparing and administering the following medication for Resident #83:Metoprolol Tartrate 25 MG Tablet x 0.5 tabletReconciliation of Resident #83's physician orders showed the following orders:Metoprolol Tartrate 25 MG Tablet - Give 0.5 tablet by mouth two times a day for htn (hypertension) hold for sb (systolic blood pressure) less than 100mmHg (millimeters of mercury) or diastolic blood pressure less than 60mmhg.A record review of Resident #83's vital signs showed on 3/17/2026 at 7:17 AM the resident's documented blood pressure was 106/58.An interview on 3/17/2026 at 9:27 AM with Staff F, LPN, was conducted. Staff F, LPN said that she takes all her resident's vital signs in the morning before medication administration. Staff F, LPN said the blood pressure was outside the parameters and she should not have given that medication.An interview on 3/17/2026 at 2:00 PM with the Director of Nursing (DON) was conducted. The DON said the nurse should have double checked the dosage before administering the medication to Resident #7. The DON said the metoprolol for Resident #83 should have been held according to the physician order.A review of the policy revised in April 2019, titled, Administering Medications, revealed Medications are administered in a safe and timely manner, and as prescribed. 4: Medications are administered in accordance with prescriber orders.10: The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage.before giving the medication.

Based on observations, records review, and interviews, the facility failed to ensure dignity was maintained related to incontinence needs for one resident (#65) out of four residents observed.Findings included: On 03/17/2026 at 09:59 AM, an observation was made of Resident #65 lying in bed. Resident #65's left leg was in a triangle position, with the knee pointing up. An observation was made of a brown mushy substance with a stool-like appearance, on Resident #65's lower left buttock area. The brown matter was between Resident #65's left buttock and the shorts. Resident #65's room had a strong odor that smelled like feces. Resident #65 stated having knowledge when he had a bowel or bladder movement. Resident #65 stated he was waiting for staff to clean him up. Resident #65 did not say if he had utilized the call light. Resident #65 said staff would go on breaks for an hour with no coverage in place, resulting in delays in being changed.On 03/17/2026 at 10:35 AM, at 10:58 AM, at 11:15 AM, and at 12:00 PM, the same observation was made of Resident #65 lying in bed with the brown matter on the left buttock area and the strong odor of feces was noted.During an interview and observation on 03/17/2026 at 12:00 PM, Staff J, Certified Nursing Assistant (CNA), observed Resident #65 in bed and confirmed the resident had a bowel movement on the left buttock. Staff J stated she was not the assigned CNA and would notify the resident's aide. Staff J left to find Resident #65's aide.During an interview on 03/17/2026 at 12:57 PM, Staff K, CNA, stated not knowing Resident #65 needed to be changed. Staff K stated having given the resident coffee between 11:00 AM and 12:00 PM and stated no odors were noticed at the time. Staff K stated not looking at Resident #65 visually to identify if there were any care needs. Staff K stated she expected Resident #65 to let her know when he needed to be changed.Review of Resident #65's medical records revealed the resident was admitted to the facility on [DATE]. Resident #65 had medical diagnoses to include chronic kidney disease, End stage renal disease, chronic pain and major depressive disorder.Review of Resident #65's Minimum Data Set (MDS), dated [DATE] section C, revealed a Brief Interview Mental Status (BIMS) score of 15, indicating cognition was intact. Section GG revealed for toileting hygiene, the resident was rated a 1, meaning the resident needed the helper to do all the effort during care. Section H revealed Resident #65 was frequently incontinent for bladder and bowel.Review of Resident #65's care plans revised on 01/28.2026 revealed a focus: Resident #65 was incontinent of bowel and bladder and required assistance with incontinence and toileting care, initiated 03/11/2025. The goal was for Resident #65 to be clean, dry, and odor free daily through the next review date. The Interventions included to provide assist with incontinence care and observe for the presence of stool.During an interview on 03/17/2026 at 01:04 PM, Staff A, Licensed Practical Nurse (LPN), stated CNAs should check on residents every two hours. Staff A stated CNAs should look at residents visually to check for care needs. Staff A stated Resident #65 lying in bowel movement for two hours should have been identified by the CNA. Staff A stated, that's unacceptable.During an interview on 03/19/2026 at 11:38 AM, Resident #65 stated he was being made to wear diapers by staff, because they hold it better. The resident stated being embarrassed about the situation and having preferred briefs.During an interview on 03/19/2026 at 11:55 AM, Staff B, LPN, Unit Manager (UM), stated Resident #65 was frequently incontinent of bowel and sometimes would not know when a bowel movement had been made. Staff B stated staff should not fully rely on residents to make care needs known and should have used other methods to identify Resident #65's care needs. Staff B stated Resident #65 wore diapers. During an interview on 03/19/2026 at 10:38 AM, the Director of Nursing (DON), stated staff were expected to check on residents every two hours. The DON stated staff were expected to ask Resident #65 if incontinent care was needed. The DON stated the staff should use visuals and smell for odors to identify incontinent care needs. The DON stated, That's just common sense. Review of a facility policy titled Quality of Life - Dignity, dated 2020, revealed:Policy Statement - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.Policy Interpretation and Implementation11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: b. Promptly responding to a resident's request for toileting assistance.

Based on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were updated and accurate, and failed to submit recommendations for a level II PASARR for two residents (#4 and #63) of two residents reviewed.Findings included: Review of Resident #63's admission record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to bipolar disorder, current episode, manic, without psychotic features (onset 3/19/2025), major depressive disorder, recurrent, moderate (onset 3/19/2025), generalized anxiety disorder (onset 3/19/2025), primary insomnia (onset 3/19/2025), unspecified dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (onset 6/21/2022). A review of Resident #63's psychiatric notes dated 2/18/2026, revealed the resident is stable on psychiatric medication. Resident #63 had diagnosis of Bipolar disorder, Major Depressive Disorder (MDD), Recurrent Generalized anxiety disorder, Dementia without behavioral disturbance and Insomnia: A review of Resident #63's Minimum Data Set (MDS), dated [DATE] for Medications, revealed the Resident is taking an antidepressant and anticonvulsant regularly. Review of the Level 1 PASARR dated 12/27/2023 and completed by an acute care facility revealed in Section I: Bipolar disorder, schizoaffective disorder, and insomnia were marked under Section A Mental Illness (MI) or suspected MI. Depressive disorder anxiety disorder were not marked. Section II: Other Indications for PASARR Screen Decision-Making questions 1 through 7 were marked no. Section III: PASARR Screen Provisional admission or Hospital Discharge Exemption Not a provisional Admission was marked no. Section IV: PASARR Screen Completion, Individual may be admitted to an Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. The review showed a level II PASARR was not submitted for consideration. On 3/19/26 at 11:55 a.m., an interview was conducted with the Director of Nursing (DON). She reviewed Resident #63's electronic health chart and confirmed the resident had diagnoses of anxiety and depression, in addition to the diagnoses that were marked in Section I. She stated the anxiety and depression diagnoses should have been marked but were overlooked. The DON stated she did not submit a Level II for the resident because the system did not trigger a Level II. The DON stated she depends on the system to trigger a Level II for residents. Review of Resident #4's admission record revealed an admission date of 12/11/2024 and initial admission of 05/07/2021. Resident #4 was admitted with diagnosis to include paranoid schizophrenia, bipolar disorder, current episode depressed, mild, epilepsy, unspecified, major depressive disorder, recurrent, unspecified and generalized anxiety disorder. Review of Resident #4 Psych note dated 02/02/2026 revealed, assessments and plan. rationale behind diagnosis Schizophrenia (confirmed diagnosis), the patient has chronic and consistent psychosis. These symptoms cause significant distress and functional impairment to the patient. The resident had diagnosis of Bipolar disorder, Major, Depressive Disorder, recurrent and Generalized anxiety disorder. Review of Resident #4's Level I PASARR, dated 03/18/2026, revealed questions 1 thru 7 were all marked no. Section III. PASARR screen is not a provisional admission was marked. Section IV. PASARR screen completion, no diagnosis or suspicion of serious mental illness or intellectual disability indicated. The review showed a level II PASARR was not submitted for consideration. During an Interview on 03/19/2026 at 11:55 a.m., the Director of Nursing (DON) stated on admissions the resident comes from the hospital with a PASARR. We go through the diagnosis and see if they have diagnosis like depressions and anxiety and add it to the PASARR. We also have psych see them to confirm the diagnosis. I know if a resident needs a level II by the information I added to the form. The form tells me if I need to submit for a level II for residents. I have not submitted any level II's for any of our residents. When I did Resident #4's PASARR it did not trigger me for a level II. Yes, she has diagnosis of schizophrenia and depression, in the past I know they would have triggered, but this time it did not. I am depending on the system to trigger me to do a level 2. Questions 1 thru 7 say no because when I read the statement it does not apply. Residents are currently not having symptoms. If resident with multiple mental illness diagnosis need a level two then there is a lot of residents who may need a level II here. A review of the Administration-PASSAR policy, revised 12/26/2025, revealed the facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability prior to admission and individuals identified with MD or ID are evaluated to receive care and services.If the PASARR Level I outcome is positive (indicating a possible serious mental illness, intellectual disability, or a related condition) then a PASARR Level II evaluation and determination must be completed prior to a nursing home admission. An individual in considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders. This mental disorder is: A schizophrenic, mood, paranoid, panic, other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder that may lead to a chronic disability.

Based on observations, interviews, and record review, the facility did not ensure 1. Medications were stored safely and out of the residents' reach for one resident (#19) out of three residents observed, and in one medication cart (West High) of 3 medication carts observed; 2. Did not ensure expired medications were discarded in one medication cart (West High) of two and in one medication room (East) of two medication storage rooms and 3. Did not ensure chemicals were not stored with wound care supplies in one storage room (East) of two observed.Findings included:1. An observation on 3/16/2026 at 9:26 AM of Resident #19 revealed two medications at bedside, antiseptic mouth rinse and ammonium lactate 12% lotion. The resident was not in room at the time. A follow -up interview and observation was conducted on 3/16/2026 at 12:35 PM with Resident #19. The observation revealed the same medications still at bedside. Resident #19 said he won the antiseptic mouth rinse at bingo a few weeks ago. He did not speak of the ammonium lactate lotion.An observation was made on 3/16/2026 at 2:45 PM of the residents playing bingo. Underneath the cart holding the bingo balls on the second shelf, was 2 bottles of antiseptic mouthrinse.An interview on 3/16/2026 at 2:46 PM with Staff E, Certified Nursing Assistant (CNA)/Activities Assistant was conducted. She said the stuff on the cart's second shelf was prizes for the residents that they win during bingo. This cart was left unattended periodically and accessible to all the residents participating in the game.An observation on 3/16/2026 at 9:47 AM of the [NAME] High medication cart revealed two boxes of inhalation medications. The cart was observed unattended in a hallway where everyone was walking through to include residents and guests.An interview was conducted on 3/16/2026 at 9:49 AM with Staff D, LPN, Unit Manager. She said the inhaled medications should not be on the top of the medication cart. She said she did not know where the nurse was.2. An observation on 3/16/2026 at 12:20 PM of the [NAME] High medication cart revealed an unopened insulin pen with a label, refrigerate on the box and two inhalers that were opened with no date as follows: Budesonide and formoterol fumarate dihydrate inhalation aerosol 120 inhalations, 113 remaining. Fluticasone Propionate and Salmeterol inhalation powder - 60 inhalations, 54 remainingAn observation on 3/16/2026 at 12:20 PM of the [NAME] High medication cart revealed three expired medications as follows: Bisacodyl 5mg - expired 2/2026 CoQ10 100mg - expired 2/2026 Carisoprodol 250mg Tablet - expired 2/6/2026An interview on 3/16/2026 at 12:30 PM with Staff C, Licensed Practical Nurse was conducted. She verified the Bisacodyl 5mg and CoQ10 100 mg were expired. Staff C said the insulin pen should have been stored in the refrigerator since it was not opened yet. She said she does not know why the inhaled medications were not labeled.An observation on 3/16/2026 at 1:50 PM of the East Side Medication Storage Room refrigerator revealed a box labeled, Avonex. Inside the box was two sealed syringes that expired on 11/2025; bleach wipes, and a box of bisacodyl suppositories which had expired in 10/2025. The bleach wipes and the bisacodyl suppositories were stored on the same shelf with no divider. On the shelf above the oxygen tanks there was a box of nicotine transdermal packages that expired in 11/2025, and a box of nicotine lozenges that expired on 1/2025, Gvoke hypo pen (for low blood sugar emergency) expired in 12/2025, and a bottle of elder tonic that expired in 1/2026.An interview was conducted on 3/16/2026 at 2:05 PM with Staff B, LPN Unit Manager. She said all the nurses are responsible for cleaning the medication rooms. She said she and the DON (Director of Nursing) would go behind and assure the medication rooms are cleaned and there are no expired medications. She verified the medications were expired and did not know why the medications were in the medication room.3. An observation on 3/16/2026 at 2:13 PM of the East Side Wound Care Cart revealed in the bottom drawer a container of bleach wipes laying over and was stored with wound care supplies. The wound care supplies were not opened. An interview on 3/16/2026 at 2:15 PM with Staff A, Licensed Practical Nurse was conducted. She said she thought the bleach and the supplies could be stored together.An interview was conducted on 3/17/2026 at 2:00 PM with the DON. The DON said the nurses are responsible for cleaning and checking for expired medications. She said the unit managers should have been checking the medication carts and storage rooms. She said the expired medications should have been discarded. She said medications should not be at the residents bedside. She said she was unaware that antiseptic mouth rinse was being given to residents as gifts after winning Bingo. She said a lot of residents that reside in the facility have a history of alcohol or drug abuse.An interview on 3/19/2026 at 3:25 PM with the NHA was conducted. He said the nursing staff was responsible for cleaning the medication rooms and carts. He said the medications should have been discarded. He said the mouth rinse should not be given to the residents and left unsecured at the bedside table.A record review of the policy revised in 2/2023 titled, Medication Labeling and Storage, the policy heading The facility stored all medications and biologicals in locked compartments.; 2: The nursing staff is responsible for maintaining medication storage; 3: If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; 6: Medications requiring refrigeration are stored in a refrigerator located in the medication room; (Photographic Evidence Obtained)

Based on observations, record review and interviews, the facility failed to ensure residents who smoked followed the facility's smoking rules/policies regarding observed loose smoking items inside the facility, and residents smoking unsupervised within the facility's parking lot, for three residents (#51, #32 and #30) out of thirty-four residents reviewed, during two days (3/16/2026, 3/18/2026) of four days observed. Findings included: Review of the facility's resident admission packet acknowledgement documents revealed a document titled, Resident Smoking Policy: Infraction notification, signed by Resident #51, #32 and #30 showing, [Name of Facility] maintains a smoke free environment. Smoking is, therefore, prohibited in any interior space, including . Parking and Driveway areas, or any other common area not designated as a smoking area. On 3/16/2026 at 10:30 a.m. an observation of the facility's parking lot revealed three male residents #51 and #32 and an unknown resident huddled up in between two cars and were observed smoking cigarettes, within the facility property. The residents were observed with their own cigarettes and smoking lighting devices. There were no staff observed outside with these residents, who were smoking on facility property. On 3/16/2026 at 1:00 p.m. Resident #51 was observed in his room. During the interview, he revealed he did smoke and either goes out in the smoking area to smoke, or signs himself out on Leave of Absence (LOA) to leave the facility to smoke. Resident #51 revealed the facility kept his cigarettes and he checked them out from the smoking supervisor out in the smoking porch. He stated he holds his cigarette lighter and takes it with him when he leaves the building. Resident #51 then picked up a clear yellow lighter from off his bedside dresser and presented it for observation. The lighter had fluid inside. Resident #51 revealed he knew he was supposed to check the lighting device in to the smoking supervisory staff prior to and after he was done smoking. Resident #51 stated it was easier that he kept his lighting device rather than to check it in and out all the time. Review of Resident #51's medical record revealed he was admitted to the facility on [DATE] with a primary diagnosis of Post Traumatic Stress Disorder (PTSD). Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; a Brief Interview Mental Status( BIMS) score of15 out of 15, which indicated intact cognition. Review of the most current smoking assessment for Resident #51 dated 3/23/2023 revealed; Resident assessed as being able to smoke independently or with set up. Section 03(c) maintenance of smoking materials did not indicate if resident maintains or if facility maintains. Review of the 3/16/2026 Nursing Quarterly Comprehensive Evaluation, smoking evaluation section revealed; not scored, revealing Resident #51 scored (0), which indicated Resident #51 was a safe smoker. Review of the current care plans with a next review date 6/6/2026 revealed focus – Resident #51 desires to smoke. Resident has been assessed as able to smoke independently. Resident has been informed of the facility smoking policy. The interventions revealed: Monitor for signs of unsafe smoking practices. Provide assistance with lighting cigarette in resident - designated smoking area. Maintain smoking materials in designated area. Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed. On 3/16/2026 at 10:30 a.m. and on 3/18/2026 at 9:50 a.m. Resident #32 was also observed to have his personal cigarette lighting device on his person when visited in his room. During the interview, the resident did not want to comment on why he had his own smoking lighting device while in his room. On 3/17/2026 at 10:00 a.m. and 3/18/2026 at 10:30 a.m. Resident #32 and two other unknown residents were observed in the same place in the parking lot back behind the facility, smoking within facility property, and without staff supervision. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) and Nicotine Dependence, Cigarette use. Review of the Annual MDS assessment dated [DATE] revealed Resident #32 had a BIMS score of13 of 15 which indicated intact cognition. Review of the Nursing Quarterly Comprehensive assessment dated [DATE] revealed; Section for smoking = Total score of 0, which indicated Resident #32 was deemed a safe smoker. Review of Resident #32's current care plans with a target date of 6/12/2026 revealed Resident #32 desires to smoke. Resident has been assessed as able to smoke with supervision. He has been informed of the facility smoking policy. Interventions included: Monitor for signs of unsafe smoking practices. Return smoking material to designated staff upon re-entry to the facility from LOA. Maintain smoking materials in designated area. Review of Resident #32's Safe Smoking Agreement, signed by the resident on 9/12/2025 revealed rules to include: Keep all smoking paraphernalia (cigarettes, lighters, e cigarettes etc.) secure, with our smoking aide. Residents may not have any smoking paraphernalia on them at any time per center for resident and center safety; Residents will only smoke in designated area and this is the courtyard only. If resident has an LOA they must sign out and sign back in with their nurse. During a tour of the facility on 03/16/2026 at 10:10 a.m., Resident #30 was observed with a red transparent lighter on his bedside table. Resident #30 explained having taken the lighter the night before and had not mentioned it to the staff. Resident #30 stated sometimes he kept the lighter.Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of COPD. Review of Resident #30's Minimum Data Set, dated [DATE], section C revealed a BIMS score of 15 out of 15 meaning the resident was cognitively intact of 15, which indicated cognition intact. Review of Resident #30's care plans revealed a focus - Resident #65 desires to smoke. Resident #65 has been assessed as able to smoke independently. Resident #30 has been informed of the facility smoking policy, initiated 10/16/2025. The goal was for Resident #30 to adhere to the smoking policy daily through the next review date, revised 01/12/2026. Interventions included to monitor for signs of unsafe smoking. Return smoking material to designated staff upon re-entry to the facility from leave of absence. Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers and supervisors if needed. On 3/18/2026 at 1:31 p.m. an interview with the smoking attendant aide, Staff G. Staff G reported he keeps all cigarettes and lighters for current smoking clients locked in smoking cart. Staff G stated he handed each resident one cigarette at a time. He stated he would light it for the residents. Staff G reported he had a list of current residents who require assistance and a smoking apron is provided during smoking. Staff G stated the nursesassess new residents for safety. Staff G stated when residents leave on LOA they are provided with their smoking lighters and they are to check them back in to put in the cart after they return to the facility. Staff G confirmed when residents leave on LOA to smoke, they must leave the facility property, to include the parking lot. Staff G revealed he had seen residents in the back parking lot smoking and stated he told them they must leave the property to smoke. Staff G stated having spoken with the management regarding those observations. On 3/19/2026 at 2:30 p.m. an interview with the Nursing Home Administrator (NHA) confirmed the facility allows for residents to have smoking activities in designated areas, which included the inner courtyard, an open space and with shade. The NHA stated they have general smoking times and there is always a staff member to assist and supervise them. The NHA stated the smoking supervisor has been trained and educated on the smoking rules and policies and will man a cart outside where all the cigarettes and smoking lighters are locked up. The NHA revealed himself, the activities staff and the social worker will go to the store to purchase the resident's cigarettes. However, there are residents who are able to and check themselves out on Leave Of Absence (LOA), and they purchase cigarettes out in the community and bring them back. He stated that residents who do bring cigarettes back to the facility have to give them to staff so they can be locked up in the smoking activities/supply cart. The NHA stated for resident smokers who signed out LOA, they can go to the smoking supervisor and check out their cigarettes and lighting devices, and they must sign out and leave the property to smoke. The NHA stated those residents should be leaving the entire property, including the parking lot. The NHA confirmed he did know there has been times when several residents would check out LOA and loiter in the end of the parking lot, or the back of the facility parking lot and smoke there. The NHA stated he has educated residents and staff to ensure they leave the entire property. He confirmed that some residents who leave on LOA will at times bring back smoking lighting devices and keep them on their person or in their room. He said unfortunately there are residents that still try to keep lighting devices on their own. Review of the undated facility smoking policy revealed it is the policy or this facility to establish and maintain safe resident smoking policies. in accordance with resident's rights and preferences and in accordance with Life Safety Code requirements and state and local laws governing safe practices for the facility.Procedure: Prior to, or upon admission, residents shall be informed in writing and sign acknowledgment that smoking is permitted in designated areas only, and that smoking articles of any kind arc to be; stored at the nursing station (or area designated by the facility) and not permitted to be stored in residents sleeping or living quarters.All residents will be evaluated by licensed nursing staff regarding smoking preferences upon admissions, quarterly, and with a significant change in resident mental or physical condition. All residents who smoke will be further evaluated for risk factors, responsibility, and will be orientated to smoking areas and procedures. Any Resident that goes LOA will be requested to turn in any smoking articles or paraphernalia.Smoking Articles:All residents who smoke will not be permitted to keep any smoking articles/paraphernalia in their room or on their person, this includes but is not limited to the following: cigarettes, lighters of any kind, matches .Lighter Fluids, 'to include butane gas, or any other forms of gas or fluids shall not be retained by the resident at any time, either in his/her possession or within his/her living or sleeping areas. Photographic evidence obtained.

Based on observations, records review, and interviews, the facility failed to follow contact isolation precaution protocols in one room (9) out of one room observed with contact precautions.Findings included: On 03/19/2026 at 01:20 PM, Staff I, Certified Nursing Assistant (CNA), was observed entering room [ROOM NUMBER], without a gown or gloves. On 03/19/2026 at 01:21 PM, Staff F, Licensed Practical Nurse (LPN), was observed entering room [ROOM NUMBER], without a gown or gloves.An observation of the room's door revealed a Contact Precaution sign on it. with the words STOP in red. The sign revealed: everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also; Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care or more than one person.During an interview on 03/19/2026 at 01:21 PM, Staff I, CNA, stated gown and gloves were only needed for contact precaution signs, and when making contact with the resident. Staff I stated the contact precaution sign on room [ROOM NUMBER]'s door was for B bed and stated, I just know. Staff I stated the contact sign did not specify the bed it was assigned to, in order to protect the residents' identity. Staff I reviewed the caution sign and stated gown and gloves were not needed before entering room [ROOM NUMBER], because contact was not made with the resident.During an interview on 03/19/2026 at 01:26 PM, Staff F, LPN, stated that gown and gloves were only needed for contact precaution signs, and when making contact with the resident. Staff F stated not having donned a gown, because contact was not made with a resident in room [ROOM NUMBER]. Staff F confirmed room [ROOM NUMBER] had a contact precaution sign and that it required gown and gloves prior to entry. Staff F stated having gone into room [ROOM NUMBER], without gown and gloves, because medication was provided to a resident and no contact was made with the resident.During an interview on 03/19/2026 at 1:56 PM, the Director of Nursing (DON), who was also the Infection Preventionist (IP), stated rooms with contact precaution signs, required gloves, gown, and mask if respiratory, prior to entry. The DON/IP stated precaution signs should have corresponding resident bed identifiers on them. The DON/IP stated staff were getting enhanced barrier precautions and contact precautions mixed up. The IP stated the actions of the staff were not appropriate. Review of an undated facility policy titled, Infection Prevention and Control Program revealed: Policy Statement- An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Surveillance:2. Process surveillance collects data that indicates adherence to infection prevention and control practices, for example:a. hand hygieneb. appropriate use of PPEc. appropriate use of, and procedures during, transmission-based precautions. f. Infection control practices during resident care. (Photographic evidence obtained)

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and five errors were identified for two (#54 and #55) of three residents observed. These errors constituted a 11.9% medication error rate. Findings included: 1. On 11/30/23 at 7:53 a.m., an observation of medication administration with Staff E, Licensed Practical Nurse (LPN), was conducted with Resident #54. The staff member dispensed the following medications: - Aspirin 81 milligram (mg) Enteric Coated tablet over-the-counter (OTC) - Iron 325 mg OTC tablet - Multi-Vitamin with mineral OTC tablet - Coenzyme Q 10 OTC tablet - Vitamin B12 1000 microgram (mcg) OTC tablet - Tamsulosin 0.4 mg capsule - Clopidogrel 75 mg tablet - Metoprolol Tartrate 50 mg tablet - Pantoprazole 20 mg Delayed Release (DR) tablet - Sertraline 50 mg tablet - Amlodipine 10 mg tablet - Oxycodone Immediate Release (IR) 5 mg tablet Staff E confirmed dispensing 12 tablets/capsules prior to entering Resident #54's room and administering the medications. A review of Resident #54's November Medication Administration Record (MAR) showed the resident was ordered on 11/20/23, Sertraline 50 mg - Give 75 mg by mouth one time a day for depression. 2. On 11/30/23 at 8:24 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #55. The staff member obtained a blood glucose level of 424 from the resident. The resident had been served breakfast and had finished a bowl of oatmeal. The staff member dispensed the following medications: - Cefdinir 200 mg capsule - Clopidogrel 75 mg tablet - Vitamin B12 1000 mcg OTC tablet - Eliquis 2.5 mg tablet - Famotidine 2- 10 mg tablets - Fluticasone nasal spray - Folic acid 1 mg tablet - Isosorbide mono 60 mg Extended Release (ER) tablet - Lisinopril 10 mg tablet - Metoprolol Succinate 50 mg ER tablet - Nifedipine ER 60 mg tablet - Levetiracetam 500 mg tablet - Humalog insulin KwikPen 15 units Staff A dialed the insulin pen to 15 units, explaining 5 units for a standing order and 10 units per the sliding scale of 424. The observation identified the staff member was unable to document the location of administration of the sliding scale insulin, a notice on the electronic record revealed a progress note would need to be completed. The staff member stated she would have to reach out to the Unit Manager as the system was not allowing documentation. Staff A administered the oral medications, administered insulin into the the left abdominal quadrant, and allowed the resident to self-administer nasal spray into each nostril. The staff member asked the resident if they remembered the education (on administration) and reminded the resident to smell the [NAME]. Immediately following the medication administration, Staff A returned to the medication cart and charted with the administration of 5 units that 10 units sliding scale was administered and MD notification. The order for Resident #55's sliding scale instructed staff were to administer units (10) and call MD for a blood sugar (level) of greater than 400. The staff member documented a blood sugar of 424 with the standing insulin order and 400 for the sliding scale of same insulin. The observation did not reveal the MD was notified and review on 11/30/23 at 10:00 a.m. and on 12/1/23 at 2:12 p.m., of the resident's Medication Administration notes did not show the MD was notified of the residents 424 blood glucose level. A review of the Resident #55's November Medication Administration Record (MAR) showed Staff A documented the resident had received the ordered Fluticasone-Salmetrol 100/50 mcg/act aerosol powder, had administered one (1) tablet of Levetiracetam not the ordered 3, and did not document the administration of Fluticasone Propionate Nasal Suspension. The staff member did not prime/air shot the insulin pen prior to the administration of the medication, stating priming was done with the first dose after opening the pen but did not have to after that. The policy - Administering Medications, revised April 2019, identified Medications are administered in a safe and timely manner, and as prescribed. The interpretation and implementation of the policy revealed: - The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. - Medications are administered in accordance with prescriber orders, including any required time frame. - The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed, and the signature and title of the person administering the drug. During an interview on 12/1/23 at 2:26 p.m., the Director of Nursing (DON) stated the expectation was to have no errors and staff were to follow physician orders. The DON said the staff do not prime insulin pens and manufacturer was discussed, the DON stated she did not know insulin pens were to be primed. The manufacturer website, https://uspl.lilly.com/humalog/humalog.html#ug1, instructed uses on Priming your Pen. The instructions identified the reason for priming the Humalog insulin KwikPen was: Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The manufacturer instructed: - Step 6: To prime your Pen, turn the Dose Knob to select 2 units. - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose.

Based on observations, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment for residents living on one (West) out of two units. Findings included: An observation was made on 11/28/23 at 10:20 a.m. of the discoloration of the hallway floor in the doorway of room [ROOM NUMBER]. An observation was made on 11/28/23 at 10:21 a.m., of a string-like material embedded onto the floor in the doorway of room [ROOM NUMBER]. The observation revealed a raised substance attached to the floor in the hallway outside of room [ROOM NUMBER]. An observation on 11/28/23 at 10:34 a.m., was of the stained privacy curtain in room [ROOM NUMBER]. An observation on 11/28/23 at 10:45 a.m., was made of a dusty privacy curtain track for the B-bed of room [ROOM NUMBER]. An observation on 11/28/23 at 11:08 a.m., of a broken dresser next to the B-bed of room [ROOM NUMBER]. The observation identified an glucose test strip in the corner of the bathroom doorway leading to room [ROOM NUMBER]. On 11/30/23 at 10:27 a.m. the test strip continued to be located in the corner of room [ROOM NUMBER]'s bathroom doorway. An observation on 11/30/23 at 7:40 a.m., revealed discoloration of the floor in room [ROOM NUMBER] in comparison to the hallway floor immediately in front of the resident room. An observation on 11/30/23 at 7:52 a.m., revealed the baseboards in the hallway of the [NAME] hall was stained with a white unknown substance. On 11/30/23 at 5:45 p.m., a tour of the facility was conducted with the Environmental Service Director (ESD). The ESD reported being at the facility for 4 months and during that time had been short staffed by 2 full-time and 1 part-time housekeeper. She stated the department had begun stripping and waxing floors two nights a week at the end of October. The ESD stated the baseboards look dirty because of floor stripper not being cleaned off before drying. She confirmed an observation of cobwebs in the corner next to an outside door next to room [ROOM NUMBER]. The ESD took an ink pen and pried the glucose test strip off the floor. She stated privacy curtains were to be cleaned monthly and staff were to notify her of dirty ones. The ESC reported resident rooms were deep cleaned and privacy curtain tracks were cleaned monthly. The policy - Method of Cleaning, undated, revealed: Every facility in our system may have different dynamics to deal with, and every situation should be handled accordingly. But some general cleaning practices, routines, and systems need to be put in place and followed. Here are some broad methods to keep in mind when training and following up with staff. The policy educated staff of the following: - TOP DOWN: always start cleaning surfaces, ledges, shops, etcetera., at the top and work your way down. Clean the face of areas as well. - Move furniture around, clean behind not commonly moved furnishings. If a resident is present, speak with them, and let them know what you are doing. - Privacy check privacy curtains, linens, and the overall condition of the room (Note any maintenance concerns). - Remove all debris from floors, counters, and edges. (Photographic evidence was obtained)

Based on observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-Admission Screening and Resident Review (PASRR) and to correct the document for six (Residents #9, #72, #18, #51, #43, and #26) out of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses. Findings included: 1. A review of Resident #9's Admission Record showed an original admitted [DATE]. The Admission Record included diagnoses and onset dates not limited to bipolar disorder (2/26/19), recurrent major depressive disorder (2/26/19), generalized anxiety disorder (2/26/19), and unspecified psychosis not due to a substance or known physiological condition (2/9/13). A review of Resident #9's PASRR, dated 11/2/16, showed the resident had a Serious Mental Illness (SMI) of bipolar disorder. The PASRR did not include the resident's diagnoses of recurrent major depressive disorder, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #9's Level II Determination Summary Report, dated 8/27/13, showed the resident was diagnosed with mild recurrent major depressive disorder. The report did not include the diagnoses of bipolar disorder, generalized anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. A review of Resident #9's annual Minimum Data Set (MDS), dated [DATE], revealed the resident was not considered to have a serious mental illness and/or intellectual disability. The comprehensive assessment identified the resident had a seizure disorder or Epilepsy, anxiety disorder, psychotic disorder, bipolar disorder, and recurrent major depressive disorder while receiving antianxiety, antidepressant, and hypnotic medications. The Advanced Practitioner Registered Nurse (APRN) note, dated 11/7/23, revealed the resident had a medical history of generalized anxiety disorder, bipolar disorder, and paranoid thoughts and behaviors. The Social Service Director (SSD) stated on 12/1/23 at 8:33 a.m., she would notify the Director of Nursing (DON) when a new PASRR was needed and the DON was the only person able to complete a new PASRR. The SSD stated on 12/1/23 at 8:46 a.m., Resident #9 had a level I PASRR and the diagnoses of bipolar and psychosis was not captured in a Level II and should have been redone. 2. A review of Resident #72's Admission Record showed the resident was admitted on [DATE] with diagnoses of unspecified convulsions, unspecified recurrent major depressive disorder, and unspecified anxiety disorder. The Admission Record revealed diagnoses with onset dates of unspecified insomnia (3/8/23), mild current episode depressed bipolar disorder (8/9/22). A review of Resident #72's PASRR, dated 4/28/22, showed the resident had a mental illness or suspected mental illness of anxiety disorder and did not include the diagnoses of unspecified recurrent major depressive disorder, unspecified insomnia, and mild current episode depressed bipolar disorder. A review of Resident #72's quarterly Minimum Data Set (MDS) dated [DATE], did not include PASRR information. The comprehensive assessment revealed the resident had a seizure disorder or Epilepsy, anxiety disorder, depression (other than bipolar), and bipolar disorder. The resident received antipsychotic, antidepressant, and hypnotic medications. During an interview, on 12/1/23 at 8:49 a.m., the Social Service Director reviewed Resident #72's PASRR and medical diagnoses and stated the diagnoses of depression and bipolar were not captured on the resident's PASRR and should have been redone. 3. A review of Resident #18's Admission Record revealed Resident #18 was admitted to the facility initially on 10/16/2018 and readmitted on [DATE] with diagnoses to include but not limited to Unspecified Adult Failure to Thrive, Schizoaffective Disorder Bipolar Type, Type 2 Diabetes Mellitus without Complications, Major Depressive Disorder, Bipolar Disorder, Unspecified, Anxiety Disorder, Unspecified. A review of the Quarterly MDS dated [DATE], showed section C- Cognitive Patterns, Brief interview for Mental Status, BIMS score of 14 which indicated the resident had intact cognition. A review of Resident #18's level one Pre-Admission Screening and Resident Review (PASRR) dated 7/16/2019 showed, Resident # 18 had no Mental Illness or suspected Mental Illness indicted. There was no PASRR referral for a level II resident review upon newly diagnosis of Major Depressive Disorder, Single Episode, Unspecified, Bipolar Disorder, Unspecified, Schizoaffective Disorder, Bipolar Type. During an interview on 12/1/2023 at 8: 30 a.m., with the Social Worker (SW), she said she was responsible for reviewing and making sure the PASRR's were completed and updated accurately. She said Resident #18's PASRR should have been updated and referred for a Level II upon his new diagnoses, but it was not done. 4. A review of Resident #26's Admission Record revealed Resident #26 was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus with diabetic neuropathy, Major Depressive Disorder, insomnia, and other co-morbidities. A review of Resident #26's PASRR Level I Assessment, dated 10/28/2020 revealed no qualifying mental health diagnosis and no PASRR Level II was required. A review of Resident #26's Admission Record revealed a new diagnosis of Post-Traumatic Stress Disorder (PTSD) on 11/09/2021, bipolar disorder on 5/24/2023, schizoaffective disorder on 06/06/2023 and the resident was not assessed for PASRR Level II. A review of Resident #26's MDS with an Assessment Reference Date (ARD) of 09/26/2023 revealed diagnoses of schizophrenia, bipolar, depression, and post-traumatic stress disorder and the resident was not assessed for PASRR Level II. A review of the medical record revealed the resident was not assessed for PASRR Level II. 5. A review of Resident #43's Admission Record revealed Resident #43 was admitted on [DATE] with diagnoses of anxiety, cognitive communication deficit and other co-morbidities. A review of Resident #43's PASRR Level I Assessment, dated 10/26/2021 revealed a diagnosis of anxiety with no other qualifying mental health diagnosis and no PASRR Level II was required. A review of Resident #43's MDS with an ARD of 08/24/2023 revealed diagnoses of Parkinson's Disease, anxiety, depression, and schizophrenia. A review of the medical record revealed the resident was not assessed for PASRR Level II, with the new mental health diagnoses. 6. A review of Resident #51's Admission Record revealed Resident #51 was admitted on [DATE] with a diagnosis of psychosis and other co-morbidities. A review of Resident #51's PASRR Level I Assessment, dated 12/18/2020 revealed no qualifying mental health diagnosis and no PASRR Level II was required. A review of Resident #51's Admission Record revealed a new diagnosis of psychotic disorder with delusions, Mood Disorder, major depressive disorder, recurrent, moderate on 2/25/2021, and schizoaffective disorder on 09/21/2021 and the resident was not assessed for PASRR Level II. A review of Resident #51's MDS with an ARD of 08/15/2023 revealed a diagnosis of depression, psychotic Disorder and schizophrenia. A review of the medical record revealed the resident was not assessed for PASRR Level II, with the new mental health diagnosis. During an interview on 12/01/2023 at 8:31 a.m., the Social Service Director (SSD), verified Resident #26, #43 and #51's admission PASRR did not reveal the resident's current mental health diagnosis'. The SSD said with a new mental health diagnosis the resident would need a new PASRR Level II completed. During an interview on 12/01/2023 at 10:14 a.m., the Director of Nursing (DON) stated the expectation was a Level II PASRR should be completed for a new qualifying mental health diagnosis. The DON stated, We need to revamp our process. A PASRR policy and procedure was requested during the survey. No policy and procedure was given to the surveyors prior to exit. 46498 48223

Based on observation, interview, and record review, the facility failed to coordinate dental services in accordance with professional standards of practice for one (Resident #17) of six residents sampled for dental care. Findings included: On 11/28/2023 at 10:00 a.m. Resident #17 was observed laying down in bed and missing her bottom teeth. Resident #17 said she has a hard time eating her food because she was missing a few teeth. She said she spoke with the dentist when they came to the facility and told them that she wanted dentures so she could eat her food properly. She said she had been waiting for awhile for someone to get back to her regarding her dentures, but she has not heard back from social services or the dentist. A review of the Admission Record showed Resident #17 was admitted to the facility on [DATE] with diagnoses to include but not limited to end stage renal disease, functional dysphasia, and, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. A review of the dental care plan, dated 4/4/2023, with a target completion date of 4/26/2023, showed Resident #17 had natural teeth with no dental issues. can perform oral care. Review of the care planned interventions showed to observed resident for care, loose or broken teeth, oral lesions, bleeding, mouth pain, report to physician as needed. A review of an email communication titled, External Newly Enrolled Residents - [faciltiy name], dated 8/22/2023, showed Resident #17 was enrolled in the dental program effective September 2023. Review of the [Provider Name] Dental Services Patient Progress Report, dated 10/24/2023, showed Resident #17 was present for oral care. It was noted that the resident had upper full, and lower partial dentures. An interview was conducted on 11/30/2023 at 3:28 p.m. with the Social Services Director (SSD). She said the facility had a contract with [Provider Name] but only the residents who were eligible could get enrolled. Resident #17 was seen by [Provider Name] on 7/ 26/2023, 9/14/2023, 10/30/2023 and 11/29/2023. Resident #17 mentioned to [Provider Name] that she wanted dentures, but there was a billing problem at that time, so the resident did not receive her dentures. The SSD said she expected [Provider Name] to follow up with Resident #17 or her family to coordinate care regarding obtaining her dentures. The SSD said she should have followed up with [Provider Name] to make sure those services were being coordinated or looked for an outside dental service that could have accommodated Resident #17 needs. Review of the facility policy titled, Dental Services, revised December 2016, showed the Policy Heading as: Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan care. Policy Interpretation and Implementation 1. Routine and 24-hours emergency dental services are provided to our residents through: a. Contract agreements with a licensed dentist that comes to the facility monthly: b. Referral to the resident's personal dentist; c. Referral to community dentists; or d. Referral to health care organizations that provide dental services. 4. Selected dentist must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs. 6. Social Service representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under state plan, if eligible.

Based on observation, record review, and interview, the facility failed to ensure laboratory tests were obtained per physician orders and acted upon in a timely manner for two (Residents #86 and #43) out of three residents sampled for laboratory services. Findings included: 1. Review of Resident #86's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The resident's Admission Record included diagnoses not limited to type 2 Diabetes Mellitus with hyperglycemia, unspecified anxiety disorder, unspecified atrial fibrillation, essential hypertension, and unspecified not intractable epilepsy without status epilepticus. A medication administration note on 10/3/23 at 10:55 a.m., documented by Staff F, Licensed Practical Nurse (LPN) revealed Resident #86 had no behaviors at that time. A review of Resident #86's Situation, Background, Assessment, and Recommendation (SBAR), dated 10/3/23 identified the resident suffered a fall. The evaluation revealed the physician was notified at 12:00 p.m. on 10/3/23 of the fall and recommended labs/education/floor mats. The evaluation did not include any additional information on the Change in Condition and did not identify the education provided or which labs had been ordered by the physician. The SBAR Summary note, effective 10/3/23 at 12:08 p.m., and written by Staff I, LPN/Unit Manager (UM), showed Resident #86 was observed on the floor beside bed and the resident had reported sliding out of bed. The note revealed the primary care physician was notified of the fall, had ordered labs for resident, bed at lowest position and floor mats. The note did not identify the type of labs ordered for the resident. The situation portion of the evaluation instructed staff to obtain at the time of evaluation resident/patient vital signs, weight, and blood sugar. The documented blood pressure, pulse, respiration rate, temperature, and oxygen level was obtained at 9:45 a.m. on 10/1/23, 2 days prior to the incident. A review of Resident #86's October Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not identify any laboratory tests were ordered on 10/3/23 by the physician. The progress notes for Resident #86, dated 10/3, 10/4, 10/5, and 10/6/23 did not identify the resident had refused any laboratory testing. A review, on 11/30/23 of the Laboratory vendors binder located on the East wing nursing station did not reveal labs had been requested to be drawn for Resident #86 on 10/3, 10/4, 10/5 or 10/6. On 11/30/23 at approximately 1:30 p.m., Staff F, Licensed Practical Nurse (LPN) said when a laboratory order was received, staff got paperwork, and wrote the lab request in the vendor's binder. On 11/30/23 at 2:04 p.m., Staff F stated when a resident refused lab tests, staff called the primary physician, and documented the refusal. Staff F was not aware of what labs were ordered on 10/3/23 for Resident #86. Staff F said when lab results came through the computer, staff reviewed them, and faxed the results to whoever ordered them unless it was critical results then the provider was called and staff documented the notification. During an interview on 11/30/23 at 2:13 p.m., the Director of Nursing (DON) reviewed the facility's documentation of Resident #86's fall on 10/3/23 and confirmed the report did not show labs were ordered. The DON reported the resident refused lots of treatments, labs, and accucheck's (glucose monitoring). She reviewed the progress notes from 10/3/23 and confirmed the physician had been notified of the resident's fall and labs were ordered and Staff I had completed, on 10/3/23, the SBAR and progress note. The DON stated the expectation was if a resident refused, staff were to notify the physician and if they continued to refuse they would be care planned for the refusal. She stated even if care planned for refusal staff was to reapproach and try again, wouldn't mean stop trying we would keep trying. The DON reviewed lab results for Resident #86 and confirmed there were no results from 10/4/23 and stated results would have been reported to the facility by 3 p.m., the facilities electronic medical record was integrated with the lab. She stated she printed out the lab requisition, put it into the vendors binder under the date to be drawn. The lab came every morning and checked the orders on the unit. On 11/30/23 at 2:28 p.m., the DON reviewed the progress note and asked Staff I what labs were ordered on 10/3/23. Staff I reported not remembering which labs were ordered for Resident #86. The DON stated the resident had come back from the hospital with intravenous antibiotics and was very non-compliant with care. She confirmed there was no documentation the resident had refused labs on either 10/3 or 10/4 and stated nurses had to get into the habit of documenting refusals. The care plan for Resident #86 included the following focuses and interventions: - Has potential for complications related to (r/t) an alteration in cardiac function due to (d/t) diagnosis (dx) of: hyperlipidemia, hypertension (HTN), and atrial fib. The interventions instructed staff to Labs & diagnostic tests as ordered; update physician of results. - (Resident) prefers to deviate from plan of care with treatments, refusing wound care, is capable of understanding risks associated with deviation from plan of care. (Resident's) physician is aware of his wishes. The interventions included: Inform resident/responsible party about risks related to deviation from plan of care, use calm approach. Explain cares. If refusing or resisting care; reapproach later, and Update physician of resident's deviation from plan of care. The policy- Medication and Treatment Orders, revised July 2016, identified Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy revealed: - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. 48223 A review of Resident #43's Minimum Data Set (MDS) dated [DATE] showed Resident #43 with diagnoses of: Parkinson's disorder, schizoaffective disorder, anxiety, cognitive communication deficit and other co-morbidities. A review of the resident's psychiatric provider note dated 10/24/2023 revealed the resident being referred by staff due to Manic symptoms. Providers recommendations were: Depakote ER 500 mg once daily, may want to increase this dose after checking level. Will start resident on Seroquel 200 mg nightly. LABS; Depakote level and CMP (comprehensive metabolic profile) in am. A review of Resident #43's physician Order Summary Report revealed a physician order for complete metabolic profile without eGFR and a valproic acid (Depakote) level dated 10/24/2023 with a start date of 10/25/2023. A review of Resident #43's physician Order Summary Report revealed a physician order for complete metabolic profile without eGFR and a valproic acid (Depakote) dated 10/25/2023 with a start date of 10/25/2023. A review of the resident's Psychiatric Periodic Evaluation dated 11/14/2023 revealed resident had a present problem of recent hypomanic episode. The providers recommendations were: Depakote ER 500 mg once daily, may want to increase this dose after checking level. LABS; reordered Depakote level and CMP (comprehensive metabolic profile) again (not done last). A review of the resident's medical record showed no laboratory results since August 17, 2023. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 11/30/2023 at 9:45 a.m. Staff A, LPN stated when lab orders were received, we complete the paperwork for our laboratory to come out then place the order on the Treatment Administration Report (TAR). The TAR informed the nurse when the laboratory should be coming for the blood draw. Staff A, LPN confirmed there was an order for a CMP and Depakote level in October, 2023. Staff A, LPN stated, I cannot find the results. The labs must not have been drawn as they are not signed off as completed on the TAR I don't know why they would not have been completed Staff A said Resident #43 was complaint with labs and medications. Review of the facility policy and procedures titled, Lab and Diagnostic Test Results - Clinical Protocol dated November 2018 showed: Assessment and Recognition: 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff: 1. When test results are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): a. The individual's current condition and details of any recent changes in status, including vital signs and mental status; b. Major diagnoses, allergies, current medications, any recent pertinent lab work, actions already taken to address results and treat the resident/patient, and pertinent aspects of advanced directives (for example, limitations on testing and treatment); c. Having diagnostic tests were obtained (for example, as a routine screen or follow up; to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level); d. Our test results may relate to the individual's current condition and treatment; e. Any concerns and questions the physician will be expected to address regarding the resident. 3. A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: a. As routine screen or follow up; b. To assess a condition change or recent onset of signs and symptoms; c. To monitor drug level. (1) The reason for getting a test often affects the urgency of acting upon the result. (2) If the reason for performing the test cannot be identified, the nurse should proceed as though the tests were ordered to assess a condition change or recent onset of signs and symptoms. Identifying Situations that Warrant Immediate Notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -The physician has requested to be notified as soon as result is received. -Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for the comparison. 2. High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed by the physician laboratories may differ in their ranges of abnormal and their criteria for panic results.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a manner such that unauthorized personnel, visitors, and residents did not have access to medications in three medication carts, one of two treatment carts, and ensure overstocked medications were stored in a locked medication room. Findings included: On 11/28/23 at 10:18 a.m., the unlocked and unattended West-Low medication cart was observed parked in a hallway leading to staff offices on the [NAME] hall. After photographic evidence was obtained, Staff A, Licensed Practical Nurse (LPN) arrived to the cart and stated I locked it before confirming the cart had been unlocked. On 11/30/23 at 7:25 a.m., the [NAME] hall treatment cart was observed unlocked and unattended while parked next to the West-High medication cart. Staff E, LPN, confirmed the cart should have been locked. During the task of medication administration, on 11/30/23 at 8:36 a.m., 5 over-the counter (OTC) medication bottles were left on the West-High cart as Staff E was in a resident room administering medications. When returning to the cart an unknown resident was observed sitting in a wheelchair within speaking distance to the staff member. On 11/30/23 during a medication administration observation at 8:36 a.m., Staff A confirmed the Humalog insulin KwikPen was opened and undated with the date of opening. The staff member stated it was probably opened yesterday as it was a new order. The staff member placed the insulin pen in the medication cart without dating it. The Humalog manufacturer showed on the website, https://uspl.lilly.com/humalog/humalog.html#ug1, instructed users to Throw away the HUMALOG Pen you are using after 28 days, even if it still has insulin left in it. On 12/1/23 at 10:07 a.m., an observation was made of a bookcase inside the East Hall Unit Manager's office, located in the resident's day room. One shelf of the bookcase held multiple bottles of the liquid medication Lactulose, another shelf had multiple blister packs of medications (one was Gabapentin) banded together, and one shelf held a box of nebulizer medication. Staff I, Licensed Practical Nurse/Unit Manager (LPN/UM), stated the medications were overstock that did not fit in the medication carts. On 12/1/23 at 10:20 a.m., after an interview, Staff I left the office and the hall leaving the door open and the medications unattended, two residents were sitting in the day room and one resident was sitting directly outside of the room. On 12/1/23 at 10:25 a.m., Staff G, LPN confirmed the medications continued to be on the bookshelf and the door was open. The staff member was observed on phone then went into the day room and locked the Unit Manager's office door. On 12/1/23 at 10:33 a.m., an observation was conducted with Staff F, LPN of the East-Low medication cart. The cart contained 5 medication bottles, each contained a vial of undated insulin. The staff member confirmed the bottles were dated but the insulin vials were not dated. Each of the vials had a pharmacy tag attached with a space to write the open date. On 12/1/23 at 10:40 a.m., an observation of West-High medication cart was conducted with Staff H, LPN. The third drawer of the cart contained 2 unidentified loose tablets. On 12/1/23 at 2:33 p.m., the Director of Nursing (DON) said when medications were to be returned to the pharmacy, they were bagged up and the Unit Manager kept them in the office for pharmacy to take back. The DON stated overstock medications, as described by the Unit Manager, were to kept in the med room not in the office. The DON stated vials of insulin should be dated on the little pharmacy tab label, and loose pills get pushed out of the packaging. The DON was aware of the observation of the unlocked medication cart (West-Low) and the treatment cart (West). The policy - Administering Medications, revised April 2019, identified During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. The policy - Medication Labeling and Storage identified The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The policy interpretation and implementation revealed: - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. - Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. - Multi dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, record review, and interview, the facility failed to monitor the blood pressure related to the use of a hypotensive medication and to administer a hypotensive medication within the physician ordered parameters for two (Residents #39 and #59) out of five residents sampled for unnecessary medications. Findings included: 1. A review of Resident #39's Admission Record revealed the resident was admitted on [DATE] and with diagnoses not limited to unspecified Cardiomyopathy, essential (primary) hypertension, and unspecified atrial fibrillation. A review of Resident #39's Order Summary Report, active as of 12/1/23, showed the resident was ordered the following: - Midodrine HCl oral tablet 5 mg - Give 1 tablet by mouth every 8 hours as needed for hypotension. Ordered 10/14/23. The Order Summary Report did not include an order to obtain Resident #39's blood pressure. Review of Resident #39's November 2023 Medication Administration Record (MAR) showed the resident's blood pressure had not been obtained every 8 hours related to the administration of Midodrine. The Weights and Vital Summary identified the blood pressure of Resident #39 had not been obtained on 11/5, 11/9, 11/18, 11/19, 11/23, 11/27, and 11/29/23. The summary revealed the resident's blood pressure had been obtained one time on 11/1, 11/2, 11/3, 11/4, 11/6, 11/7, 11/8, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/16, 11/17, 11/21, 11/22, 11/24, 11/25, 11/26, 11/28, and 11/30/23. The resident's blood pressure had been obtained twice on 11/10 and 11/20/23. The care plan for Resident #39 included the following focus: - Has the potential for complications related to an alteration in cardiac function due to (d/t) diagnosis (dx) of hypertension (HTN), a-fib, hyperlipidemia, and hypotension. The interventions related to this focus instructed staff to administer medications as ordered, observe for effectiveness and for side effects, and to obtain vital signs as ordered and as needed. On 12/1/23 at 3:01 p.m., the Director of Nursing (DON) stated staff should be obtaining blood pressures for Resident #39 every 8 hours and there should be hypotension parameters for the use of Midodrine. 2. A review of Resident #59's Admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to paroxysmal atrial fibrillation and atherosclerotic heart disease of native coronary artery without angina pectoris. A review of Resident #59's Order Summary Report, active as of 12/1/23, identified an order for Midodrine hydrochloride (HCl) 5 milligram (mg) - Give 2 tablet by mouth every 8 hours for hypotension (HTN), Hold Midodrine if systolic blood pressure (SBP) greater than (>) 110. The review of November Medication Administration Record (MAR) identified Resident #59 had been administered Midodrine 53 out of 90 opportunities despite a SBP of greater than 110. A review of Resident #59's care plan included the following focus area: - Has potential for complications related to an alteration cardiac function due to diagnosis of Coronary Artery Disease (CAD), hyperlipidemia, and hypertension. On 12/1/23 at 2:53 p.m., the Director of Nursing (DON) confirmed staff were medicating Resident #59 with Midodrine for a systolic blood pressure greater than 110, outside of ordered parameters. The DON stated staff were not reading the (physician) orders. The review of September, October, and November 2023 Pharmacy Medication Regimen Review (MRR) identified there were no pharmacy recommendations for either Resident #39 or Resident #59. The policy - Medication Therapy, revised April 2007, revealed Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. All medication orders will be supported by appropriate care processes and practices.

Based on observation, record review, and interview, the facility failed to store the urinary catheters of two (Residents #70 and #60) out of seven residents in a sanitarily manner and to obtain physician orders for the care of an urinary catheter for one (Resident #60) out of the two sampled residents. Findings included: 1. An observation was made on 11/28/23 at 10:25 a.m. of Resident #70 sitting in a wheelchair in the East-hall day room. The resident's urinary drainage bag was observed hanging from the bottom of wheelchair with tubing containing golden milky liquid lying on the floor. Photographic evidence was obtained. On 11/28/23 at 10:28 a.m., Staff I, Licensed Practical Nurse/Unit Manager (LPN/UM), was observed putting Resident #70's catheter tubing into a privacy bag. The staff member stated she observed the tubing (on the floor) when she witnessed this writer taking a photo of the tubing. A review of Resident #70's Admission Record showed the resident was admitted on [DATE] and included the diagnoses of unspecified neuromuscular dysfunction of bladder and unspecified chronic kidney disease stage 3. A review of Resident #70's Order Summary Report included orders instructing staff to change the urinary catheter bag and tubing once monthly and as needed for blockage or signs of infection and to ensure the resident had a securing device for the urinary catheter as needed for prevention of tugging and pulling. The review of Resident #70's care plan showed the resident had an alteration in elimination as evidence by (AEB): is continent of bowel, (pronoun) is at risk for constipation related to (r/t) impaired mobility-non ambulatory, has indwelling Foley urinary catheter r/t diagnosis (dx) neurogenic bladder, dx Benign prostatic hyperplasia, chronic kidney disease stage III (CKD III). The interventions included but not limited to maintain closed drainage system and keep drainage bag below level of the bladder. Provide catheter privacy bag. A review of Resident #70's comprehensive Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. The MDS revealed the resident required extensive 2-person assist for bed mobility, total dependent upon 2-persons for transfers and toileting. 2. An observation was made of Resident #60's catheter hanging from the bottom of the resident's wheelchair with the catheter tubing and drainage bag lying on the floor. (Photographic evidence was obtained). A review of Resident #60's Admission Record showed the resident was admitted on [DATE] and readmitted on [DATE]. The record included a diagnosis not limited to unspecified neuromuscular dysfunction of bladder. A review of Resident #60's Order Summary Report, active orders as of 12/1/23, showed the report did not include physician orders for the care of the resident's urinary catheter. A review of Resident #60's November Medication and Treatment Administration Records (MAR/TAR) showed no physician orders for the care of the resident's urinary catheter and revealed staff had not documented the care of the resident's urinary catheter. On 12/1/23 at 9:34 a.m., Resident #60 said the staff cleaned the catheter every day, three times a day. A review of Resident #60's October TAR included physician orders instructing staff: - Change urinary catheter bag and tubing once monthly and and as needed every night shift every 1 month starting on the 10th for 28 days, discontinued on 10/18/23. - Ensure resident has securing device for urinary catheter, discontinued 10/25/23. - Perform urinary catheter care with soap and water every shift, discontinued 10/25/23. The care plan for Resident #60 revealed the resident had an alteration in elimination AEB (as evidenced by): has indwelling (Foley) catheter d/t neurogenic bladder and colostomy, risk for constipation d/t impaired mobility - does not ambulate. 11/4/23 Vaginal yeast infection-resolved. The interventions included but not limited to: - Irrigate urinary catheter with 30-60 cubic centimeters (cc) Normal Saline (NS) as needed (PRN) for blockage or sluggishness. - Provide catheter care and pericare every (q) shift and as needed. - Maintain closed drainage system and keep drainage back below level of the bladder. Provide catheter privacy bag. - Observe catheter function every (q) shift and empty bag as needed. Observe for color, order, clarity. During an interview on 12/1/23 at 2:38 p.m., the Director of Nursing (DON) stated the urinary tubing should not be stored on the floor. The Cleveland Clinic article - Urine Drainage and Leg Bag Care, located at https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care, revealed: - Arrange the catheter tubing so that it does not twist or loop. When you are getting into bed, hang the urine bag beside the bed. You can sleep in any position as long as the bedside bag is below your bladder. Do not place the urine bag on the floor.

46498 Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one (Resident #17) of one sampled residents for dental services. On 11/28/2023 at 10:00 a.m., Resident #17 was observed laying in bed dressed in her night cloths, and missing her bottom teeth. During an interview on 11/28/2023 at 10:00 a.m., Resident # 17 said she had a hard time eating her food because she was missing a few teeth. She said she spoke with the dentist when they came to the facility and told them that she wanted dentures so she could eat her food properly. She said she had been waiting for a while for someone to get back to her regarding her dentures, but she had not heard back from social services or the dentist. A review of the Admission record showed Resident #17 was admitted to the facility on [DATE], with diagnoses to include but not limited to End Stage Renal Disease, Patient's Noncompliance with other Medical Treatment and Regimen Due to Unspecified Reason, Unspecified, Functional Dysphasia, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Bipolar Disorder Unspecified, Unspecified Psychosis not Due to a Substances Known Physiological Condition. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed Section C- Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident # 17 had intact cognition. A review of the Dental care plan dated 4/4/2023 with a target completion date of 4/26/2023, showed Resident #17 had natural teeth with no dental issues and can perform oral care. Review of the care plan intervention showed to observed the resident for cares, lose or broken teeth, oral lesions, bleeding, mouth pain, report to physician as needed. An interview was conducted with Staff B, License Practical Nurse (LPN)/MDS Coordinator. Staff B said MDS was responsible for creating and revising care plans. She worked in the office with another MDS staff member. She was responsible for the Quarterly assessments, but she opened the assessment for each department head to review and complete their sections. She did not know what happened to Resident #17's Quarterly assessment and why it was not showing it was updated. When she opened the resident assessment, it showed the care plan was created on 4/4/2023 and the next review was 1/16/2023. There was a note in the resident's chart showing it was reviewed but the review date was not reflected in the system. The nurses were responsible for completing the resident's assessment related to dental care. Staff B said I should have revised the care plan to reflect the resident had missing teeth and made changes to her interventions, It's an error on my part. A review of the facility policy titled, Care Planning - Interdisciplinary Team dated March 2022, showed policy statement: The interdisciplinary team is responsible for the development of the resident care plan. Policy Interpretation and Implementation 1. Resident care plans are developed according to the timeframes and criteria established by S 483.21. 2. Comprehensive, person-centered care plan are based on the resident assessments and development by an interdisciplinary team (IDT)

Based on observation, interview, and record review, the facility failed to ensure one (Resident #55) of three residents sampled failed to have a baseline care plan developed and implemented within 48 hours of admission. The findings include: Review of Resident #55's Admission Record revealed, Resident #55 was admitted on [DATE] for short term rehabilitation and was successfully discharged home on 11/18/2023, return not anticipated. Resident #55 had a change of condition and was readmitted on [DATE]. Resident #55 was admitted with the following diagnoses: seizures, acute kidney failure, diabetes, pleural effusion, atherosclerotic heart disease, atrial fibrillation, asthma, major depressive disorder, and other co-morbidities. Review of Resident #55's physician orders showed: Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 37.5 MG per day for depression; Depakote ER Oral Tablet Extended Release 24 Hour 250 MG (Divalproex Sodium) give three (3) tablets at at bedtime for epilepsy; Humalog Kwikpen 100 UNIT/ML Solution pen-injector, Inject 5 unit, three times a day for diabetes; Levetiracetam Oral Tablet 500 MG (Levetiracetam) give 3 tablet, two times a day for epilepsy; Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 20 unit at bedtime for diabetes. On 11/28/2023 at 8:30 a.m., Resident #55 was observed sitting on the edge of the bed. Resident #55 stated I just got back; I fell at home. On 11/29/2023 at 1:40 p.m., an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D stated knowledge of residents' care comes from the computer. Staff D stated knowledge of Resident #55 from a prior admission, as nothing was in the computer for Resident #55. An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager on 12/1/2023 at 9:45 a.m. Staff C stated when a new admission came into the facility, the nurse admitting or readmitting the resident completed an Admission Nursing Comprehensive Eval-BCP V9 2. Staff C stated this document had the baseline care plan imbedded in the evaluation. Documents were printed and discussed with the resident and/or responsible party. An interview was conducted with the Director of Nursing (DON) on 12/1/2023 at 10:00 a.m. The DON stated the expectation was the nurse admitting the resident completed the Clinical Admission Evaluation with the base line care plan. The nurse had 48 hours to develop and discuss the base line care plan with the resident and/or responsible party. The DON confirmed the Admission Nursing Comprehensive Eval-BCP V9 2 was blank where the base line care plan information should have been. Review of the facility policy and procedures titled Care Plans - Baseline dated March 2022 showed: Policy: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation: 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum health care information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussions with resident/representative; b. Physicians orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendations, if applicable. 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed 4. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medication and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. 5. Provision of the summary to the resident and/or resident's representative is documented in the medical record.

Based on observation, interview and record reviews the facility failed to ensure one resident (#3) was assessed and determined to be clinically appropriate and safe to administer medications of the seven residents sampled. Findings included: An observation on 6/21/23 at 9:30 a.m. revealed three medications unattended on Resident #3's bedside table. (Photographic Evidence Obtained) Resident #3 was interviewed in his room on 6/21/23 at 9:47 a.m. During the interview Resident #3 stated the pills were his morning pills and described them as a vitamin, an antibiotic for a boil that popped, and an antacid. Review of Resident #3's Medication Administration Record (MAR) for June 2023 showed no order for self-administration of medications and his morning oral medication regimen was: *Cephalexin 500 milligrams by mouth every 12 hours for left buttock cellulitis for 10 days at 0600 (6:00 a.m.), *Divalproex ER 500 milligrams by mouth one time a day at 0900 (9:00 a.m.), *Vitamin D3 125 micrograms by mouth one time a day for vitamin deficiency at 0900, *Famotidine 20 milligrams by mouth in the morning for gastro esophageal reflux disease at 1000 (10:00 a.m.). On 6/21/23 at 11:30 a.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B said medications should not be on the bedside table or left in resident rooms and nurses are expected to observe residents take their medications. Staff B stated she was unaware the medications were in the room. Staff B said Resident #3 had a disagreement with the nurse from the previous shift about receiving his insulin and the medications may have been left over from the morning. On 6/21/23 at 2:09 p.m. during an interview with the Assistant Director of Nursing she stated medications should never be left in resident rooms for them to take later, and it is basic nursing to observe residents take their medications. Review of facility policy titled, Administering Medications, revised April 2019, showed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determine that they have the decision-making capacity to do so safely. Review of facility policy titled, Medication Labeling and Storage, revised February 2023, showed: Policy Statement The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications for several residents.

Based on interview and record review, the facility failed to notify the Physician of a medical change in condition in a timely manner for one (Resident #1) of three residents reviewed. Findings Included: On [DATE] at 3:20 p.m., a phone interview was conducted with Resident #1's family member that indicated she was not happy with the facility. She said the resident had returned to the facility just a week ago after staying at a local hospital. She stated on [DATE], she visited the resident and found him not alert and delirious. She said she informed a nurse that she had wanted him sent out to the hospital, but the nurse would not send him out. She said, On [DATE] my uncle visited him and said he needed food, they tried to get him to sit up to eat. He ate a little bit of food at that time. My uncle had left the room to get something and on his way back people were in his bedroom. My Uncle said he overheard them say 'he has no heart rate and his BP is up'. My uncle said they started performing CPR (cardiopulmonary resuscitation) on him. A review of the medical record revealed Resident #1 was readmitted to the facility on [DATE]. The Admission Record form revealed Resident #1 had resided at that facility for eight years and was middle aged. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The History and Physical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress notes dated [DATE] at 1:39 a.m., revealed resident's blood sugar was 67 at the beginning of the shift and his blood pressure (BP) was ,d+[DATE]. A call was placed to the physician on call. New orders were received for insulin and to put parameters on BP medications. At 5:19 a.m., accu-check (blood glucose level) was 333, resident refused insulin. No documentation of physician notification. A review of the physician orders dated on [DATE] at 1:31 a.m. revealed [MEDICATION(S)] R insulin before meals and at bedtime (hs) with medium as ,d+[DATE] =0, ,d+[DATE] 3 u (units), ,d+[DATE]=5 u, ,d+[DATE]=8 u, ,d+[DATE]=10 u, ,d+[DATE]=12 u, >400 =15 u before meals and at bedtime for dm (Diabetes Mellitus). The physician's order did not include orders to perform blood glucose levels (BGL). A review of the treatment administration record (TAR) revealed for, [MEDICATION(S)] R insulin, a check mark and nursing initial on [DATE] at 06:30 a.m. and at 1130 a.m. No documentation was in place that reflected how much insulin had been administered. Review of the Blood Pressure Summary documentation dated [DATE] at 2:55 p.m. revealed blood pressure at ,d+[DATE]. No documentation was found that indicated the Physician was notified of the hypertension episode. On [DATE] at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). She confirmed no documentation was found for Resident #1 on [DATE] related to his BGL at 333 and the refusal of insulin. She confirmed there was no documentation of the blood glucose level, nor if Insulin was administered on [DATE] at 06:30 a.m. or 11:30 a.m. She also confirmed the physician was not notified of the hypertensive episode on [DATE] . A review of the progress notes on [DATE] at 4:11 p.m. (16:11) revealed the nurse found the resident in his room unresponsive. Vital signs showed no pulse, no breathing, started Cardiopulmonary Resuscitation (CPR) on resident, primary care doctor called and notified. Paramedics called. CPR continued when paramedics arrived. Will continue to monitor. Review of Emergency Medical Services Patient Care Report dated [DATE] Call received at 1557 (3:57 p.m.) At scene 1600 (4:00 p.m.) Transported at 16:29 (4:29 p.m.) Dispatched to Skilled Nursing Facility (SNF) to find [Resident #1] lying unresponsive with nursing performing BLS (Basic Life Support) CPR, Pt had a chief compliant of [CONDITION(S)]. Nursing stated that pt. was acting at normal baseline 30 minutes prior to [CONDITION(S)]. Pt's family on scene stated that pt. was acting abnormal approximately 2 hours prior to [CONDITION(S)]. On [DATE] at 3:00 p.m., a phone interview was conducted with Resident #1's physician. He said he knew Resident #1 and had given the facility orders to send him out to the ER for an evaluation. The physician said he had not been notified an hour earlier of the resident's blood pressure of ,d+[DATE]. Nor had he been informed the resident had a blood sugar reading of 333 in the morning and the resident refused his Insulin. The Physician confirmed it was his expectation he was notified of a change in vital signs timely and that included an episode of [CONDITION(S)] with the resident refusal of Insulin. Review of Policy Change in a Residents Condition or Status dated February 2021 Policy statement Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident medical/mental condition and or status.

Based on observations, record reviews, and interviews the facility failed to provide bathing as scheduled for two (#1 and #2) out of two sampled dependent residents sampled. Findings included: 1. Resident #1 was admitted on [DATE] and 1/25/22 according to the Admission Record, and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out 15, indicative of an intact cognition. The MDS indicated the resident had no occurrences of rejection of care and the Activity of Daily Living (ADL) task of bathing did not occur over the entire 7-day period. The Functional Status of the resident indicated other ADL tasks, such as bed mobility, dressing, and personal hygiene required physical extensive assistance from one person and the resident had bilateral lower extremity impairment. An interview was conducted, on 2/25/22 at 9:37 a.m., with Resident #1 who reported not wanting to be at facility, would be different if she could get up and move around but cannot. The resident reported not getting baths regularly. The resident reported bath nights were to be on Tuesdays and Thursdays and had not received a bath on either night this week. The review of the facility's Shower Schedule identified Resident #1 was to receive a shower/bath on Tuesday and Thursday on the evening shift. A review of Resident #1's Certified Nursing Assistant (CNA) January 2022 Task report identified the resident was unavailable (due to hospitalization ) on 1/13 through day shift on 1/25/22. The report indicated the task of bathing was Not Applicable on the day shift of 1/1, 1/2, 1/4 (Tuesday), 1/9 - 1/12, and 1/29, Not Applicable on the evening shift on 1/1, 1/3, 1/8, 1/9, 1/11 (Tuesday), 1/12, and 1/27 (Thursday) through 1/30. The report did not include documentation that any bathing had occurred on the day shift of 1/3, 1/5, 1/6 (Thursday), 1/26, 1/27 (Thursday), 1/28, 1/30, and 1/31 or the evening shift on 1/2, 1/5, 1/6 (Thursday), 1/25 (Tuesday), 1/26, and 1/31/22. The Task report identified the resident was dependent upon one person for a bed/towel bath on the day shift on 1/7 and 1/8, during the evening shift on Tuesday 1/4, 1/7, and required physical help in part of the bathing activity with 2 persons for a shower on Monday 1/10/22. A review of Resident #1's February 2022 CNA Task bathing report identified the resident required total dependence with one person assistance for a bed/towel bath on the day shift of 2/5 and 2/6, the evening shift on Tuesday 2/1, Thursday 2/3, 2/6, 2/21, and Tuesday 2/22, required partial assistance from one person for a shower during the day shift on 2/19, required one-person assistance with transferring during the evening shift for a bed/towel bath on 2/2 and 2/16, and required physical assistance from one person for an evening shift on Thursday 2/24/22. The report indicated that during the day shift the bathing task was Not Applicable on the day shift on 2/2, 2/4, 2/7 - 2/15, 2/17-2/18, 2/20-2/21, and 2/23- 2/24 and was Not Applicable during the evening shift on 2/4, 2/5, 2/8, 2/9, 2/11, 2/12, 2/19, 2/20, and 2/23/22. The report did not include documentation that a bath or shower was completed on the day shift on 1/1, 1/3, and 1/16, or on the evening shift on 2/7, Thursday 2/10, 2/13 - Tuesday 2/15, and 2/18/22. The January and February CNA bathing task reports identified the resident received five showers/baths out of twelve opportunities during the scheduled Tuesday and Thursday baths, with one resident refusal. The resident did not receive any bath or shower after returning from the hospital during the evening shift of Tuesday 1/25 until the evening shift on Tuesday 2/1, a total of seven evening shifts; and did not receive a bath or shower for nine days from 2/7 through 2/16/22, in which the resident was scheduled for three baths during that time. The reports identified the resident refused one opportunity for a bed bath or shower on Thursday 2/17/22. A review of Resident #1's care plan included the following focuses and interventions: - Has potential for skin impairment/pressure ulcers related to (r/t) impaired mobility, requires staff assist to turn and reposition, diagnosis (dx) of Diabetes Mellitus (DM), dx of Peripheral Vascular Disease/Peripheral Artery Disease (PVD/PAD). The interventions instructed staff to observe skin for signs/symptoms (sx/sx) of breakdown during care. - Here for Long Term placement due to (d/t) need for 24-hour supervision/care. Unable to care for self-status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Requires assistance with Activities of Daily Living (ADL's). Is a mechanical transfer Hoyer lift. The interventions instructed staff to praise the efforts of the resident participation in care. - Has a self-care deficit with ADL's r/t impaired mobility r/t limited endurance r/t Chronic Obstruction Pulmonary Disease ([CONDITION(S)]), resident participates with ADLs with cues from staff. Some days resident participates better than others. She requires lots of encouragement on these days. The interventions instructed staff to allow resident ample time to attempt/complete ADL tasks before intervening and to provide hands on assistance with dressing, grooming, (and) bathing as needed. - Has alteration in mood/behavior, prefers to remain mostly in bed, claims she is too tired, exhibits little to no interest in doing things. Will get up for beauty shop visits and occasional music or food activities (acts). The interventions instructed staff to assist with getting up and out of room on days that the beauty shop is open. During an interview on 2/25/22 at 12:22 p.m., the Assistant Director of Nursing (ADON) stated Resident #1 was getting bed baths. The ADON reviewed the resident's CNA bathing documentation and confirmed the resident did not get a bath from 2/7 to 2/16/22. The ADON stated if the resident reported not getting a bath this week, she would believe the resident. 2. Resident #2 was admitted on [DATE] and readmitted on [DATE] and 2/12/22 according to the Admission Record with identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score for Resident #2 of 12 out of 15, indicating a moderate cognitive impairment. The MDS indicated the resident exhibited no rejection of care and required total dependence from one person for personal hygiene and bathing. The facility Shower Schedule identified that Resident #2 was to be assisted with a shower during the day shift on Mondays and Wednesdays. A review of the January Certified Nursing Assistant (CNA) bathing task report indicated that the bathing task was Not Applicable during the day shift on 1/1, 1/2, Monday 1/3, 1/4, 1/7, Monday 1/10, 1/11, Wednesday 1/12, 1/13, 1/15, Monday 1/17 - Sunday 1/23, 1/25, 1/26, 1/28, and 1/29/22. The staff had documented that the bathing task was Not Applicable during the evening shift on 1/2, Tuesday 1/4 - Monday 1/17, 1/20, 1/21, Monday 1/24 - 1/29/22. The report identified that Resident #2 was total dependent upon one person for a bed/towel bath during the day shift on Thursday 1/6 and Friday 1/14, during the evening shift on 1/1 and 1/31, and required physical help in part of the bathing activity from one-person for a bed/towel bath on Wednesday 1/19 and 1/23/22. The January report identified the resident did not receive bathing from 1/2 until 1/6, from 1/6 to 1/14 (eight days), from 1/15 to 1/19, 1/20 to 1/23, and 1/24 through 1/30 (seven days). A review of the February CNA bathing task report identified that Resident #2 did not receive bathing from the evening shift on 2/1 until the day shift on 2/9, a total of seven days, as staff had documented the bathing task was Not Applicable. The care plan for Resident #2 identified the following focuses and interventions: - Has an alteration in visual function as evidence by (AEB) the use of eyeglasses to read large print. The staff were to intervene by providing assistance with ADL tasks as needed. - Has a self-care deficit with ADL's related to (r/t) cognitive deficit, impaired mobility r/t diagnosis (dx) of [CONDITION(S)]. Was recently hospital [ized] for [CONDITION(S)] of hands. Resident participates with ADLs with cues from staff. The interventions included to cue/encourage resident to participate in ADL tasks, allow resident ample time to attempt/complete ADL tasks before intervening, and provide hands on assistance with dressing, grooming, (and) bathing as needed. The policy Supporting Activities of Daily Living (ADLs), dated 2001 and revised March 2018, reported that Residents will provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy indicated that care and services would be provided for residents who were unable to carry out ADL's independently with the consent of the resident and in accordance with the plan of care which included hygiene (bathing, dressing, grooming and oral care).

Based on observations, record reviews, and interviews, the facility failed to assess, obtain wound care orders, and provide the wound care according to professional standards of practice for one (#3) of two residents sampled for skin conditions. Findings included: On 2/25/22 at 9:52 a.m., Resident #3 was observed utilizing a motorized wheelchair in the hallway. The observation revealed a white undated 3-inch () x 3-inch island dressing attached to the lateral aspect of the resident's left knee; the dressing had brown staining on it. The resident stated the left knee kept getting banged on the doorway, pointing to the door of the resident's room. The resident reported the area was superficial, staff put a dressing on it whenever the resident asks for it, and staff last changed the dressing 3 to 4 days ago. Resident #3 was admitted on [DATE] and 1/13/22 according to the Admission Record and included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Order Summary Report, active as of 2/25/22, did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], identified the residents Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicative of an intact cognition. On 2/25/22 at 12:05 p.m., an observation was conducted with the Assistant Director of Nursing (ADON) of Resident #3's left knee. She confirmed the presence of a white dressing on the resident's left knee which was removed. The ADON stated the date written on it was worn off so could not tell what it was. The inside of the dressing had dried red-colored staining. The area under the dressing was scabbed. Immediately after leaving Resident #3's room, the ADON informed the Director of Nursing (DON) of the dressing observed and removed from the residents left knee. The DON stated all dressings for the resident had been discontinued. The ADON reviewed the electronic documentation of the resident's wounds and indicated that three of the three documented wounds indicated zero closure and did not include the left knee. The ADON informed the DON the resident had two weekly skin evaluations, one dated 11/19/21 and one on 2/9/22, she also reported that the resident did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's care plan identified that the resident was noted to have multiple scabbed and open areas to left lower extremity. The interventions instructed staff to administer medications for wound healing as ordered, observed for effectiveness and for side effects (SE's), and to perform wound treatments as ordered. The policy, Wound Care, dated 2001 and revised October 2010, identified that the purpose was to provide guidelines for the care of wounds to promote healing. The preparation portion of the policy instructed staff to Verify that there is a physician's order for this procedure. The policy indicated that documentation should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data.