Every finding on record at Bedford Wellness & Rehabilitation

Based on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Residents #1 and 2) of 3 residents reviewed for pressure ulcers.On 08/13/26, the facility failed to provide PRN wound care to Resident #1's and Resident#2 coccyx pressure wound.These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included:1.Record review of Resident #1's Comprehensive Assessment MDS, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure) and osteomyelitis, unspecified (an inflammation or swelling of bone tissue caused by a bacterial or fungal infection). MDS also revealed skin and ulcer injury treatments. Application of nonsurgical dressings (with or without topical medications) other than to feet. The resident had moderate cognitive impairment with a BIMS score of 9. Record review of Resident #1's care plan dated 07/20/26 reflected: [Resident #1] has actual impairment to skin integrity rule out trauma wounds. Goal included: Resident will be free from injury through the review date. Intervention included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury.Record review of Resident #1's physician order, dated 08/07/26, reflected the following:- Sacral Stage 3 (a deep, full-thickness wound over the tailbone/sacrum where skin is lost and fatty subcutaneous tissue is visible, though muscle, tendon, and bone are not exposed).: cleanse wound with normal saline/ wound cleanser, pat dry. Apply calcium alginate to wound bed, cover with dry dressing, every day shift every Mon, Wed, Fri for pressure injury AND as needed for wound treatment if soiled.Record review of Resident #1's Wound Care Administration Record for August 2026 reflected the Wound Care was being provided as ordered. Observation on 08/13/26 at 12:30 PM revealed ADON A and LVN B providing Resident #1 with wound care. They washed hands, put on gloves and put supplies together. They went to the room and explained the procedure to Resident #1. LVN B performed hand hygiene before contact with Resident #1. She put on gloves and unfastened the residents' brief. Resident #1 was heavily soaked in urine and bowel movement. She cleansed Resident #1's abdominal folds and perineal area (labia majora). They then positioned the resident on her side and cleansed her buttocks. The resident was observed to have wounds and had no dressing in place. LVN B removed the gloves and washed hands. She cleansed the wound with gauze soaked with wound cleanser; pat dried the wound. She removed gloves, washed hands, and put on clean gloves, applied calcium alginate and a dry dressing dated 8/13/26 then a clean brief.Record review of Resident #1's Progress Notes for August 2026 reflected there was not any information related to her wound dressing not being there on 08/13/26.2.Record review of Resident #2's Comprehensive Assessment MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure) and pressure ulcer of sacral region, stage 3 (a deep, serious wound over the tailbone area where skin is fully lost, exposing underlying fat tissue. The resident had intact cognition with a BIMS score of 15. Record review of Resident #2's care plan with a revision date of 07/23/26 reflected: [Resident #2] has Risk for Impaired Skin Integrity Wound [Resident#2] admitted [DATE] with stage 3 pressure injury to coccyx(the small, triangular bone at the very bottom of the spine), redness to both buttocks and sacrum. Goal included: Resident's Skin Will Remain Intact Without Signs of Infection. Intervention included: Monitor skin for moisture, apply barrier product as needed.Record review of Resident #2's physician order, dated 06/23/26, reflected the following:- coccyx pressure injury Clean wound with wound cleanser, pat dry. Apply Calcium alginate and collagen particles and cover with dry dressing daily and as needed if soiled or dislodged every day shift for wound treatment and as needed.Record review of Resident #2's Wound Care Administration Record for August 2026 reflected the Wound Care was being provided as ordered.Observation on 08/13/26 at 2:18 PM revealed LVN C and LVN D providing activity of daily living assessment with Resident #2, who had a urine odor, in her room. They washed hands, put on PPE, and went to the room. They explained the procedure to the resident.They performed hand hygiene before contact with Resident #2. LVN C put on gloves and unfastened the resident's brief. Resident #2's brief was soaked in urine. They turned the resident on the side, and she was observed to have open wound on the coccyx (the small, triangular bone at the very base of the spine and no dressing.Interview on 08/13/26 at 03:08 PM with LVN D revealed she was the one assigned to Residents #1 and #2 during then 6AM to 2PM shift. She stated her expectation was for CNAs to notify her if dressing got dislodged during incontinent care. She said she was not notified by her CNAs that Resident #1 and Resident #2 did not have a dressing on their wound. She said they have as needed orders to replace the dressing. She said the risk to not replacing the dressing to the wound was that it could get infected or slow the healing process.Interview on 08/13/26 at 03:20 PM with LVN B revealed she was the one that performed wound care with ADON A on Resident #1. She stated her expectation was for CNAs to notify the nurse or the wound care nurse if dressing fell off or got dislodged during incontinent care. She said she was not the nurse assigned to Resident#1,she was just helping with wound care. She said they have as needed orders to replace the dressing. She said the risk to not replacing the dressing to the wound was infection.Attempted phone interview on 08/13/26 at 3:42 PM with CNA E (who worked with Resident #1 and #2 on 6AM-2PM shift) was not successful as she did not answer.Attempted phone interview on 08/13/26 at 3:43PM with CNA F (who worked with Resident #1 and #2 on 6AM- 2 PM) was not successful as she did not answer.Interview on 08/13/26 at 3:45 PM, ADON A revealed she was the one responsible for wound care since the treatment nurse had resigned. She stated she expected CNAs to notify the nurse on the hall or her if dressing fell off or dislodged during care for replacement. She said all residents with wounds have as needed orders in case a dressing fell off or got dislodged during care. She said she was not notified Resident #1 and Resident#2 were not having dressing on their wounds. She said the risk of not having the wound covered could be infection. Interview on 08/13/26 at 4:29 PM with the DON revealed Residents #1 and #2 should have had dressing on their wounds. The DON said all wound dressing orders have the scheduled and PRN orders so that if the dressing was soiled during incontinent care, it could be replaced by the nurse on duty. The DON said the nurse on duty would have been responsible for replacing it when the CNAs had noticed it was missing or soiled. The DON said all nurses had been trained to know how to do this. He said the wound care nurse goes behind the nurses while performing wound care to make sure that all dressings were in place for residents' wounds. The DON said if residents did not receive wound care as ordered it could lead to increased risk of infection and skin damage. Interview on 08/13/26 at 5:45 PM, with wound doctor revealed her expectation was for the CNAs to notify the nurse on the hall if dressing fell off or dislodged during care for replacement. She said the risk of not having the wound covered could be infection and the wounds taking long to heal.Record review of the facility's Wound Management policy, revised 01/26, reflected: 6.Treatment implementation: Nursing staff will follow physician orders for wound dressings and treatment.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 2 of 3 residents (Residents #1 and #2) reviewed for ADL care. The facility failed to ensure Residents #1 and #2 were provided with timely incontinence care.This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings included:1.Record review of Resident #1's Comprehensive Assessment MDS, dated [DATE], reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure) and osteomyelitis, unspecified (an inflammation or swelling of bone tissue caused by a bacterial or fungal infection). The resident had moderate cognitive impairment with a BIMS score of 9. The resident was dependent for toilet transfer and toileting hygiene. Record review of Resident #1's care plan dated 07/20/26 reflected: [Resident #1] has an ADL Self Care Performance Deficit rule out osteomyelitis. Goal included: Resident will be continent at all times through the review date. Intervention included: requires extensive assist x1 staff participation to use toilet. Resident #1 has potential for bladder incontinence rule out immobility and diagnosis of osteomyelitis. Goals: Resident will maintain clean and intact skin and Measures will be taken to prevent skin breakdown. Interventions included: Ensure the resident has unobstructed path to the bathroom.2.Record review of Resident #2's Comprehensive Assessment MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure) and pressure ulcer of sacral region, stage 3 (a deep, serious wound over the tailbone area where skin is fully lost, exposing underlying fat tissue). The resident had intact cognition with a BIMS score of 15. Resident#2 was dependent for toilet transfer and toileting hygiene. Record review of Resident #2's care plan dated 07/20/26 reflected: [Resident #2] has an ADL Self Care Performance Deficit rule out impaired balance. Goal included: Resident will maintain current level of function in (specify bed mobility, transfers, eating, dressing, toilet use and personal hygiene) through the review date. Intervention included: Personal hygiene/oral care: the resident requires 1-person extensive assist with staff participation with personal hygiene and oral care.Observation and interview on 08/13/26 at 9:05 AM revealed Resident #1 in her room on her bed. She stated her brief was soiled and she was waiting to be changed, but she could not tell when last she was changed. Observation and interview on 08/13/26 at 9:13 AM revealed Resident #2 in her room on her bed. She stated her brief was changed but she could not recall when she was last changed. She stated she was not sure whether she was wet. Observation on 08/13/26 at 12:30 PM revealed ADON A and LVN B providing Resident #1 with wound care. They washed hands, put on gloves and put supplies together. They went to the room and explained the procedure to Resident #1. LVN B performed hand hygiene before contact with Resident #1. She put on gloves and unfastened the resident's brief. Resident #1 was heavily soaked in urine and bowel movement. She cleansed the resident's abdominal folds and perineal area (labia majora). They then positioned the resident on her side and cleansed her buttocks. The resident was observed to have wounds and had no dressing in place. She removed the gloves, washed hands, and put on gloves and applied a clean brief.Observation and interview on 08/13/26 at 12:40 PM revealed Resident #2 in her room on her bed. She had a urine odor. She stated she could not recall being changed since the interview in the morning. She stated she was wet. Observation on 08/13/26 at 2:18 PM revealed LVN C and LVN D providing activities of daily living assessment with Resident #2, who had an odor, in her room. They washed hands, put on PPE, and went to the room. They explained the procedure to the resident. They performed hand hygiene before contact with Resident #2. LVN C put on gloves and unfastened the resident's brief. Resident #2's brief was soaked in urine. They turned the resident and she was observed to have wound and no dressing. She did not cleanse the resident's perineal area. They then positioned the resident back in bed without cleaning her although the resident was requesting it to be changed since she saw her brief was soaked. LVN C told her she would be back with the CNA to change her and they left her wet. They removed PPE, washed hands, and they left and went to the nurse's station and continued to hand over since it was shift change. Interview on 08/13/26 at 03:08 PM with LVN D revealed she was the one assigned to Residents #1 and #2. She stated her expectation was for the CNA to round every 2 hours and as needed. She stated she was busy with resident she was sending to hospital and she did not monitor the CNAs as needed. She stated she was aware she was supposed to do rounds also every two hours and as needed, but she was busy with other residents. She stated she was not aware whether the incoming nurse and the CNA went to change Resident#2. She stated failure to round and change resident every two hours could lead to skin breakdown and if they had wounds they would worsen. Interview on 08/13/26 at 3:25 PM with LVN C, who was the evening shift nurse that did the ADL assessment, revealed staff were supposed to perform the incontinent rounds every 2 hours and as needed because Resident #2 was soaked with urine to a point she needed a brief change and she had an odor for urine. She stated LVN D who worked morning shift was supposed to monitor the CNA to ensure they completed the rounds. She said after taking over she went to the room and changed Resident #2 with her CNA and replaced the dressing. She stated leaving residents wet for a long time was that they would be predisposed to skin irritation and urinary tract infections.Attempted phone interview on 08/13/26 at 3:42 PM with CNA E (who worked with Resident #1 and #2 on 6AM-2PM shift) was not successful as she did not answer.Attempted phone interview on 08/13/26 at 3:43PM with CNA F (who worked with Resident #1 and #2 on 6AM- 2 PM) was not successful as she did not answer.Interview on 08/13/26 at 3:45 PM, ADON A revealed she expected staff to perform rounds every two hours and as needed. She stated the nurses were responsible for monitoring the CNAs during their shifts. She stated not performing every two hours rounds could lead to skin issues and infections.Interview on 08/13/26 at 4:29 PM, the DON revealed he expected staff to perform rounds every two hours and as needed. He stated the nurses were responsible for monitoring the CNAs during their shifts by performing rounds behind the CNAs. He stated not performing every two hours rounds could lead to skin issues and infections. The DON stated he had done training with staff on providing incontinence care every two hours. The DON said it was not on the facility policy that they do rounds every 2 hours, but it was the best standard of practice. Record review of training on perineal care/incontinent care dated 07/30/26 revealed LVN C, LVN D, CNA E and CNA F were not in attendance. The in-service revealed all residents should be checked and changed every 2 hours of shift. Residents should be turned in every 2 hours and monitored for incontinent care.Record review of the facility's Perineal Care policy, revised June 2020, reflected the following: . Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need. Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection.

Based on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives prior to installing a side or bed rails to include assessing the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation, and ensure that the bed's dimensions are appropriate for the resident's size and weight for 4 of 5 residents (Resident #1, #2, #3, and #4) reviewed for bed or side rails.The facility failed to: obtain consent for bed or side assist rail(s) for residents; have documentation of evaluation for bed or side assist rail(s) for residents; have ongoing monitoring/evaluation for bed or side assist rail(s) for residents; update residents' care plans for bed or side assist rail(s) for Residents #1, #2, #3, and #4)The facility maintenance team failed to have documentation of routine preventive maintenance of beds and bed rails to ensure they met current safety standards. These failures placed residents at risk of accidents and entrapment. Findings included:Record review of Resident #1's face sheet dated 07/10/26 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was diagnosed with unspecified sequalae of cerebral infraction (post stroke complications affecting physical, cognitive and emotional health), muscle wasting and atrophy, not elsewhere classified, multiple sites (significant loss of muscle tissue, leading to weakness, reduced physical function, and difficulty performing daily activities), other abnormalities if gait and mobility (encompass unusual walking patterns that affect balance, coordination, and safe movement) and cognitive communication deficit (A condition where underlying cognitive impairments, disrupt a person's ability to communicate effectively).Record review of Resident#1's MDS dated [DATE] reflected, Resident #1 had a BIMS score of 10 which, indicated mild cognition impairment.Record review of Resident #1's care plan, undated, reflected Resident #1's focus was at risk for falls r/t gait/balance problems imitated on 11/17/24. Resident#1's goal reflected she will not sustain serious injury. Resident #1's interventions reflected, .the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Resident #1's care plan had no documentation of bedside assist rail(s).Record review of Resident #1's EHR assessment section reflected no evaluation for bedside assist rail(s).Record review of Resident #1's EHR misc. section reflected no consent for bedside assist rail(s).Record review of Resident #2's face sheet dated 07/10/26 reflected a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #2 was diagnosed with Parkinson's disease with dyskinesia with fluctuations, muscle wasting and atrophy (significant loss of muscle tissue, leading to weakness, reduced physical function, and difficulty performing daily activities), not elsewhere classified, multiple sites, and Dementia in other disease classified elsewhere, mild with other behavioral disturbance.Record review of Resident #2's MDS dated [DATE] reflected, Resident #2 had a BIMS score of 04 which, indicated severe cognition impairment.Record review of Resident #2's care plan, undated, reflected Resident #2 had a focus for actual falls with minor injury, poor balance and unsteady gait. Resident #2's goal reflected, resume usual activities without further incident. Resident #2's intervention reflected, frequent rounding by staff. Resident #2's care plan had no documentation of bedside assist rail(s).Record review of Resident #2's EHR assessment section reflected no evaluation for bedside assist rail(s).Record review of Resident #2's EHR misc. section reflected no consent for bedside assist rail(s).Record review of Resident #3's face sheet dated 07/10/26 reflected a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 was diagnosed with unsteadiness on feet, unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, muscle wasting and atrophy, not elsewhere classified, multiple sites (significant loss of muscle tissue, leading to weakness, reduced physical function, and difficulty performing daily activities) and cognitive communication deficit (A condition where underlying cognitive impairments, disrupt a person's ability to communicate effectively).Record review of Resident #3's MDS dated [DATE] reflected Resident #3 had a BIMS score of 12 which, indicated moderate cognition impairment.Record review of Resident #3's care plan, undated, reflected Resident #3's focus was high risk for falls r/t gait/balance problems initiated on 12/03/24. Resident #3's goal reflected she will not sustain serious injury. Resident #3's interventions reflected, .the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Resident #3's care plan had no documentation of bedside assist rail(s).Record review of Resident #3's EHR assessment section reflected no evaluation for bedside assist rail(s).Record review of Resident #3's EHR misc. section reflected no consent for bedside assist rail(s).Record review of Resident #4's face sheet dated 07/10/26 reflected, an [AGE] year-old male admitted to the facility on [DATE]. Resident #4's was diagnosed with muscle wasting and atrophy, not classified anywhere else, multiple sites, (significant loss of muscle tissue, leading to weakness, reduced physical function, and difficulty performing daily activities) other abnormalities of gait and mobility (encompass unusual walking patterns that affect balance, coordination, and safe movement) and cognitive communication deficit (A condition where underlying cognitive impairments, disrupt a person's ability to communicate effectively).Record review of Resident #4's MDS dated [DATE] reflected, Resident #4's had no BIMS score.Record review of Resident #4's care plan, undated, reflected Resident #4's focus reflected had an actual fall 07/02/26, minor injury resulting in a skin tear due to unsteady gait and poor safety . Resident #4's goal reflected PT consult. Resident #4's interventions reflected, .the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side rails as ordered, handrails on walls, personal items within reach. Resident #4's care plan had no documentation of bedside assist rail(s).Record review of Resident #4's EHR assessment section reflected no evaluation for bedside assist rail(s).Record review of Resident #4's EHR misc. section reflected no consent for bedside assist rail(s).During an observation on 07/10/26 at 12:30 p.m., Resident #1, Resident #2, Resident #3, and Resident #4's beds had bed/side assist rail(s) attached.During an interview and observation on 07/10/26 at 2:30 p.m., the Maintenance Assistant stated he randomly checked residents' assist rails two to three times a week. Maintenance Assistant showed the two different bed types the facility used and how the railings were installed. The Maintenance Assistant stated he did not have documentation on which beds were checked and when. The Maintenance Assistant stated it was important he made sure the assist rails worked properly so that residents did not have falls and the CNAs could get the residents out of bed.During an interview on 07/10/26 at 3:30 p.m., LVN A stated she did evaluations on residents for assist rails. LVN A stated the evaluation was in the electronic health record. LVN A stated after the completion of the evaluation a written consent form was signed by the resident or legal representative before the assist rails were placed. LVN A stated Maintenance was responsible for checking the rails. LVN A stated the assist rails helped with repositioning residents and helped prevent falls.During an interview on 07/10/26 at 3:40 p.m., LVN B stated the resident or legal representative had to give written consent for the assist rails. LVN B stated the assist rails were for residents who were a fall risk and prevented falls. LVN B stated Maintenance was responsible for checking the rails.During an interview on 07/10/26 at 4:00 p.m., CNA C stated if something was wrong with the assist rails she would report it to the charge nurse. CNA C stated the assist rails helped when residents needed to be changed or get up from bed.During an interview on 07/10/26 at 4:30 p.m., the DON stated typically, the facility would evaluate residents to determine if they needed an assist rail. The assist rails are important to make sure we are getting residents out of bed to make sure they develop core body strength and socialize with other residents. The DON stated care plans are updated quarterly by IDT. The DON stated a consent form must be signed before assist bars could be put on the bed because the assist bar could be seen as a form of a restraint. The DON stated he believed medical records had the consents and were responsible for them.During an interview on 07/10/26 at 5:00 p.m., the Medical Record Director stated she did not have access to the assist rails consents and would not know where to start to find consent forms.During an interview on 07/10/26 at 5:32 p.m., the Administrator stated the nursing department was responsible for evaluation and consultation for the assist rails. Record review of the facility current, undated Maintenance Supervisor policy reflected: .Executed the company's preventive maintenance program and record keeping systems to maintain the center is at its highest level of physical function.Develops center profile and physical plant history by maintaining complete documentation of all maintenance activities including accurate records of all replacement parts and materials used.performs all routine maintenance repair work for the center in accordance to Federal, state and Local ordinance, regulations and building codes.checks bedrails, grab rails for security and proper functioning.Record review of the facility's Bed Rails policy, dated January 2026, reflected: Purpose: To ensure that bed rail use is appropriate, individualized, and based on a resident's clinical needs, while prioritizing resident safety, comfort, and freedom of movement.Resident assessment and justification: 1. Before bed rails are used, an assessment must be completed by a Licensed Nurse and/or IDT.2. If bed rails are used for mobility assistance, obtain informed consent from the resident or representative.3. If bed rails are used as a restraint, follow the restraint policy, including obtaining physician orders and care planning for gradual reduction. Documentation & Care Planning :1. The resident's care plan must be updated to reflect: . Purpose of bed rails (enabler vs. restraint). Type of monitoring and supervision provided, Strategies to address needs while using bed rails (e.g., repositioning, hydration). Ongoing monitoring and reduction efforts: 1. The IDT will review bed rail use quarterly.2. The maintenance Team will inspect bed rails at least quarterly.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 ) of 5 residents reviewed for care plans.The facility failed to update each resident's person-centered comprehensive care plan to reflect the need for EBP.This failure could place residents at risk of infection.Findings included:1. Record review of Resident #1's face sheet, dated 05/22/26, reflected an [AGE] year-old female, admitted [DATE] and readmitted on [DATE]. She was diagnosed with other subsequent encounter and dependence of renal dialysis (refers to the condition where an individual requires ongoing dialysis treatment due to compromised kidney function, rendering them incapable of effectively filtering waste products from their blood).Record review of Resident #1's physicians order summary, dated 05/22/26, reflected, Enhanced Barrier Precautions r/t (dialysis fistula) (surgically created connection between an artery and a vein, providing the safest and most effective long-term access for hemodialysis).: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices., every shift for standard precautions.Record review of Resident # 1's care plan undated, reflected no active notation of EBP.Record review of EBP list, undated, reflected Resident #1 was on Dialysis with AV fistula (surgically connection between an artery and vein that provides long-term access for hemodialysis).2. Record review of Resident #2's face sheet, dated 05/22/26 reflected he was a [AGE] year-old male who was initially admitted on [DATE] and readmitted on [DATE]. He was diagnosed with cognitive communication deficit (a condition where communication difficulties arise from impairments in cognitive processes rather than language or speech mechanics).Record review of Resident #2 's order summary dated 05/22/26, reflected no active order for EBP.Record review of Resident #2's care plan undated, reflected no active notation of EBP.Record review of EBP list, undated, reflected Resident #2 was on EBP for PEG placement (medical procedure used to place a feeding tube directly into the stomach).3. Record review of Resident #3's face sheet, dated 05/22/26. reflected a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. He was diagnosed with MRSA (is a type of bacteria that causes skin infections and is resistant to many antibiotics, making it harder to treat), presence of cardiac pacemaker ( medical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle, ensuring it beats at a normal rate) and quadriplegia, C5-C7 complete (spinal cord injury results in total paralysis and loss of sensation below the level of injury, affecting all four limbs and many autonomic functions). Record review of Resident #3's physicians order summary, dated 05/22/26, revealed Enhanced Barrier Precautions r/t (urostomy-[ surgical procedure that creates an opening (stoma) in the abdominal wall to allow urine to exit the body]., wounds) and staff members would wear a clean gown and gloves while performing high contact resident care activities including Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines. every shift for Standard precaution.Record review of Resident #3's care plan undated, revealed no active notation of EBP.Record review of EBP list, undated, reflected Resident #3 was not on the EBP list. 4. Record review of Resident #4's face sheet, dated 05/22/26 reflected she was a [AGE] year-old male admitted on [DATE]. She was diagnosed with Gastrotomy status (G-Tube) and Bretts syndrome (a rare genetic neurodevelopmental disorder that primarily affects girls, causing progressive loss of motor skills, speech, and hand function).Record review of Resident #4's physicians order summary, dated 05/22/26, revealed no active order for EBP.Record review of Resident #4's care plan undated, revealed no active notation of EBP.Record review of EBP list, undated, reflected Resident #4 was on EBP for PEG placement (medical procedure used to place a feeding tube directly into the stomach). 5. Record review of Resident #5's face sheet, dated 05/22/26, reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. She was diagnosed with cutaneous abscess of left lower limb (localized collection of pus in the skin and underlying tissues, typically caused by bacterial infection, most commonly Staphylococcus aureus), abscess of tendon sheath (a painful bacterial infection within the protective sheath surrounding a tendon, often requiring urgent medical treatment to prevent serious complications.), left thigh and encounter for other specified surgical aftercare (used to document encounters for specific postoperative care that does not fall under more common aftercare categories).Record review of Resident #5's physicians order summary, dated 05/22/26, revealed Enhanced Barrier Precautions r/t (wound): Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices . every shift for standard precautions.Record review of Resident #5's care plan undated, revealed no active notation of EBP.Record review of EBP list, undated, reflected Resident #5 was on EBP for wound.During an interview on 05/22/26 at 8:56 AM, CNA B stated when care was provided to residents on EBP he had to wear a gown and gloves to prevent infection control. CNA B stated he asked the charge nurse what he needed to wear to care for residents and he went by the sign outside the resident's door.During an interview on 05/22/26 at 9:20 AM, LVN A stated residents with wounds, indwelling catheter, dialysis sites, and g-tubes, nursing staff were responsible for wearing gowns, gloves, donning (put on) and doffing for infection control. LVN A stated there was signage outside the residents' doors to help staff remember what needed to be worn.During an interview on 05/22/26 at 11:30 AM, the IP stated residents with indwelling medical devices, and wounds were on EBP and when nursing staff provided direct contact then gown, gloves and face mask should be worn. The IP stated EBP postings were on the doorway that explained the enhanced barrier process, and PPE was found by the doorway. PPE was worn to protect staff from the residents with medical devices, for example G-tube. The IP did not know who was responsible for putting the EBP information in the care plan. The IP stated she would check with the MDS nurse.During an interview on 05/22/26 at 1:10 PM, the MDS Nurse stated Enhanced barrier precautions information should be in the care plan to know what to do to provide care to residents. The MDS Nurse stated he updated the care plans quarterly, annually, and with significant changes. The MDS Nurse stated the Treatment nurse, DON and nurse management were responsible for making updates to the care plan. During an interview on 05/22/26 at 1:45 PM, the Administrator stated it was important for care plans to be updated to ensure residents received their needed care. The Administrator stated the nurse management department was responsible for care plan updates and he would do an in service. Record review of facility policy, dated 10/24/22, titled, Care Planning reflected, Purpose to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being

Based on observation, interview, and record review, the facility failed to store, prepare, and handle food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure walk-in freezer food items were dated, labeled, and secured.The facility failed to ensure that canned good food items were free of dents.The facility failed to ensure the walk-in refrigerator food items were dated, labeled, and secured.The facility failed to ensure staff followed food safety and sanitation protocols to prevent cross contamination. These failures could place residents at risk for foodborne illness and foodborne intoxication. Findings included: During an initial brief tour of the facility's only kitchen on 12/09/2025 from 7:31 AM to 7:57 AM, revealed the following: walk-in freezer - An unsealed clear bag of hot dog, with an illegible date- An unsealed bag of beef patties in an open box, dated 12/8/2025 and labeled open- An unsealed bag of chicken legs in an open box, dated 11/20/2025- An open and unsealed box of cinnamon roll dough, undated canned good items (dry storage)- Dented can of grape jelly, dated 10-27-25- Dented can of tomato sauce, dated 9-30-25- Dented can of Champinones (mushrooms), dated 11-25-25walk-in refrigerator - An unsealed tub of sour cream, labeled opened 10/28/25 and use by 11/29/25- A large bag of pepper jack cheese cubes, undated and with manufacturer best by date 11/25/2025- Dietary Aide X in the walk-in cooler touching various products while wearing used food grade gloves. The gloves appeared to have seasonings on them. During an interview on 12/09/2025 at 7:56 AM with the Dietary Aide revealed the gloves she was wearing in the walk-in refrigerator were the same gloves used to prepare raw chicken. She said she was supposed to take them off and wash her hands because she does not want to contaminate anything else. During an interview on 12/09/2025 at 1:02 PM with the Dietary Supervisor, she said it was important food items in bag were sealed after opening because of contamination from other objects. She said it was important for frozen food items to be sealed because they can be freezer burnt. The Dietary Supervisor said the risk of canned good items was they could create a broken seal and cause contamination and botulism (foodborne illness caused by bacteria that creates botulinum toxins; consumption can lead to respiratory and muscular paralysis). Record review of the facility's Dietary Department policy, revised October 24, 2022, reflected: PurposeTo ensure that the dietary department has the requisite organization to meet the nutritional needs of residents. Policy.ProcedureI. The primary objectives of the dietary department include:.C. Maintenance of standards for sanitation and safety;D. Maintenance of standards for quality of food;E. Procurement, production and service with economical use of labor and food.H. Provision of effective supervision and training of food service personnel.V. Employee Hygiene During Food Preparation and ServiceA. Employees should never use bare hand contact with any foods, ready to eat or otherwise.Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. Disposable gloves are a single use item and should be discarded between and after each use. See Policy No. - IC - 21 - Hand Hygiene. Record review of the U.S. FDA Food Code 2022 reflected: 3-101.11 Safe, Unadulterated, and Honestly Presented. 3-201.11 Compliance with Food Law. A primary line of defense in ensuring that food meets the requirements of S 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting and processing, they do not fall victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard.3-304 Preventing Contamination from Equipment, Utensils, and Linens. 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.3-501.17 . Commercial processed food: . READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1. (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . D. (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section.

Based on interview and record review, the facility failed to ensure residents were able to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible, or the resident preferences indicated otherwise for one (Resident #1) of five residents reviewed for quality of care. The facility failed to weigh Resident #1 at admission per facility policy and physician's orders. These failures could place residents at risk for decreased nutritional and weight status and a decline in health. Findings included: Record review of Resident #1's admission MDS dated [DATE], reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a group of diseases that affect how the body uses blood sugar), muscle wasting, and atrial fibrillation (an irregular and often rapid heartbeat). The MDS reflected Resident #1's weight as 0 pounds. The MDS reflected a BIMS of 13, indicating intact cognition. Record review of Resident #1's care plan initiated on 12/11/2025, reflected Resident #1 required treatment for atrial fibrillation with an intervention that Resident #1 was to be monitored for loss of appetite. Record review of Resident #1's physician orders, written by Physician F with start date 12/04/2025, reflected Resident is at risk for malnutrition related to diagnosis: Longstanding Persistent Atrial Fibrillation, weigh weekly x 4 weeks, and monthly thereafter. Dietician to consult as needed, per orders. On 12/09/25, a record review of weights in Resident #1's electronic health record revealed a weight of 0.0 pounds completed on 12/03/2025. No other weights were present at that time. Record review of Resident #1's Skilled Evaluations for December 2025 reflected her weight as 0.0 pounds. In an interview on 12/09/25 at 01:50 pm, Resident #1 stated, they have never weighed me. She stated, I used to be about 182 pounds, and the hospital had me at 192 pounds, but I don't think that is right. In an interview on 12/11/25 at 11:20 am, ADON A stated that she was the nurse providing care to Resident #1 and on 12/10/25 she had struck out Resident #1's weight in the electronic weight record and indicated incorrect documentation when she realized that Resident #1's weight had been recorded as 0.0 pounds which was, obviously not correct. She stated she thought that the nurse who had documented 0.0 pounds in Resident #1's record had placed the accurate weight on a different resident on accident, however she did not know what other resident's chart or what nurse had made the entry. She stated the facility policy for checking weights was upon admit, every week times 4 weeks, then monthly unless it is determined to be needed more often. She stated that Restorative Aides are responsible for checking weights and that the DON was responsible for documenting the weights and identifying and responding to changes in weight. She stated the facility DON had quit last week and that ADON B would be taking over the responsibility but that she was still in training. She reported that the risk of a resident's weight not being checked according to the policy or physician order would be, the weight helps us get a baseline to monitor gains and losses. She stated she believed that the therapy department was responsible for training the Restorative Aides on checking weights. In an interview on 12/11/25 at 11:25 am, RN C stated she was remaining in the building this week as the facility DON had quit last week. She read from the facility policy that residents are to have their weights checked upon admission, every week for four weeks, and then monthly and as needed unless indicated more frequently by a physician's order. She stated that the Restorative Aides are responsible for taking residents' weights and receiving training on this from the therapy department. She stated that the Restorative Aides give the weights to the DON who documents them and identifies and responds to changes in weights or inaccuracies. She stated she thought therapy was responsible for this training. She did not state why Resident #1s' weight had not been recorded. In an interview on 12/11/25 at 12:45 pm, ADON B stated that the DON monitored and documented resident's weights but that the DON quit last week and she (ADON B) was now beginning to take that over the responsibility. She stated that Restorative Aides check resident's weights upon admission, readmission, weekly x 4 weeks, then monthly or more often as determined needed. She stated that the facility's restorative aides are knowledgeable of this. She stated she was aware of the restorative aides receiving training on weights from another restorative aide who had come from a sister facility around September 2025. ADON B stated the risk of a resident's weight not being checked per policy or order was that we could have weight gain that could be detrimental to the patient or unnecessary weight loss. There are some things we can treat if we know. She stated she did not know why Resident #1s' weight had not been checked. In a review of Resident #1s electronic weight record on 12/11/25 at 01:15 pm, a new (not previously present) entry dated 12/3/25 by ADON A reflected Resident #1s weight as 187 pounds. In an interview on 12/11/25 at 01:09 pm, ADON A reported she had entered Resident #1's weight on 12/11/25 as 187 pounds for 12/3/25 when she found the list of residents' weights sitting on the desk of the DON who quit last week. She declined to provide this list to the surveyor but stated that the spreadsheet could be obtained from the DOR. In an interview and observation on 12/11/25 at 01:20 pm, the DOR stated that Restorative Aides take residents' weights and have received training from another restorative aide who came in from another facility in September or October of 2025. She stated that once a Restorative Aide checked a resident's weight, they would write it down on a piece and then type it into a shared file spreadsheet that the DON had access to. She stated that the DON who quit last week had been responsible for entering those weights into the electronic health record. She reported that the DON would enter the weekly, monthly, admission, as needed, and all weights into the electronic health record. She stated she believed that Resident #1 was on more frequent weight checks because of congestive heart failure. She stated that if Resident #1's weight had not done by the restorative aide, that the DON would have communicated that to her and she would have had a restorative aide check the weight. She stated that by looking at the shared file spreadsheet she noted that Resident #1's weekly weight was done this week, but she was not sure about the admission weight. She provided a spread sheet from the shared file and for Resident #1 a weight was entered under a column dated 12/1/25-12/5/25, and she stated this was a concern because the exact date could not be identified. She stated that this shared file could be altered at any time by anyone with access, and there were no time-stamps or ability to track edits. In an interview on 12/11/25 at 01:45 am, Restorative Aide E stated she was responsible for checking Resident #1s weight upon admission. She stated she did check Resident #1s weight using a mechanical lift and sling, and that she gave this weight to the DOR. She was adamant that she did this weight on 12/1/25. In an interview on 12/11/25 at 2:07 pm, the ADM stated that Residents' weights were to be checked for every admission per their policy and for CHF patients. He stated that the Restorative Aides check the weights and give them to the DON who evaluates the weights for discrepancies or concerns. He stated that the DON enters them into the electronic health record. He stated that if a resident's weight was not checked, anything that is not done for the patient could possibly have a negative outcome. The expectation is to get the weight. The facility policy titled, Assessment and Management of Resident Weights with revised date of 06/2020 stated, Weights are obtained upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter. Additional weights may be obtained at the discretion of the licensed nurse or the interdisciplinary team (IDT).

Based on interview and record review, the facility failed to provide complete, accurately documented and readily accessible information in 1 (Resident #7) of 1 resident reviewed for identifiable information.The facility failed to provide the original, complete, and accurate handwritten notes taken during a meeting with Resident #7, Resident #7's family, the DON, and SW.This failure places residents at a risk of inaccurate orders that could lead to negative effects in their clinical, functional, mental, and psychosocial care.Findings included: Record review of Resident #7's face sheet revealed an [AGE] year old woman, admitted on [DATE], with a primary diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side (paralysis or weakness to the left side of the body due to a stroke). Other pertinent diagnoses include Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (decline in cognitive function).Record review of Resident #7's MDS, dated [DATE] revealed the resident had a BIMS of 13 (indication that the resident had intact cognitive function). Record review of Resident #7's progress note, dated 11/25/2025, reflected: Resident's [family] is requesting that resident's tramadol be reduced to be only to bed time and for the gabapentin to be discontinued due to it being ineffective, NP notified . Record review Resident #7's order summary, dated 12/09/2025, reflected: Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth at bedtime for pain Give 1 capsule PO QHS for pain Order Date: 9/23/2025tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for painOrder Date: 11/28/2025.The order summary did not show an active order for Tylenol. During an interview on 12/08/2025 at 12:15 PM with Resident #7's RP, they stated the family requested that the facility stop the Gabapentin because it was not having any effect on Resident#7's ankle pain. The RP stated they were in contact with the ADM, DON, ADON, and social worker, and they requested a meeting with us (Resident #7, RP, family) to discuss the issue. The RP said there was a meeting last Wednesday (12/03/2025) in Resident #7's room. The RP said based on last week's (12/03/2025) meeting, Tylenol and Tramadol will be administered as needed for pain. During an interview with Resident #7 on 12/11/2025 at 9:00AM, she revealed the Gabapentin does not work for her pain and she does not want Tramadol due to it making her drowsy. Resident #7 said she did not talk about the medications in last week's meeting and said her family communicates with the facility staff; Resident #7 prefers her family to be talked to about her care and medications. Resident #7 said she had pain in her ankle last night and did not call staff because she knew they would suggest Tramadol and she refused the Gabapentin. During an interview on 12/11/2025 at 11:33 AM with RN H, she stated Resident #7 complained of pain was prescribed Gabapentin. She said the Gabapentin did not help much, so Resident #7 was prescribed Tramadol. RN H said the Tramadol was too much, making Resident #7 drowsy and now the Tramadol was PRN . Since Tramadol has been changed to PRN, Resident #7 does not ask for it, and had refused it. RN H said if residents do not like their medication, she was to contact the provider (doctor or nurse practitioner). During an interview on 12/11/2025 at 12:21 PM with LVN I, she revealed there had been a meeting with the DON, SW and Resident #7 at Resident #7's bedside regarding care. RN I stated the SW told her that the DON had the SW document the conversation. At this time, this surveyor requested ta copy of the note. This surveyor did not receive the note. During an interview on 12/11/2025 at 1:45 PM with the ADM, stated there was a meeting on 11/28/2025 with Resident #7 and a family member. He stated it was a meeting to address grievances. He said the family wanted to discontinue Resident #7's medication order for Tramadol and the Gabapentin was not effective. The ADM indicated he was aware that the family did not want Resident #7 to take Gabapentin. He stated he asked the family to come into the facility so they could resolve the grievance, so the family and facility could be on the same page. The ADM stated the grievance was resolved by changing the Tramadol to be used as needed. He said the family has not voiced concerns since that meeting. The ADM stated Resident #7's family was very involved with her care and Resident #7 wanted her family involved; and even though Resident #7 had dementia, she had a BIMs of 13 and was able to make her own decisions. Record review of the grievance concern, dated 11/28/2025, reflected: Concern: . [Family] voiced concerned about [Resident #7's] pain medication, thinks that she may be receiving a high dose, requested clarification on the medication dosage, and also for changes to the medication.Response: Team met with resident and [family members] to clarify medication concern, MD notified, medication was clarified and concern was resolved. During an interview on 12/11/2025 at 2:29 PM with Med Aide K, he stated Resident #7s family told him the Gabapentin was not working to treat pain, and that was when Tramadol was prescribed by the nurse practitioner or doctor. He said Resident #7 was sleepier from the Tramadol, and the scheduled medication was discontinued. He said Resident #7 refused Gabapentin, but sometimes takes it, and in the last week she had not taken Tramadol. Med Aide K did not indicate if Gabapentin was supposed to be discontinued, only that Tramadol was scheduled for as needed. During an interview on 12/11/2025 at 3:15 PM with the SW, she showed this surveyor the handwritten note, on her phone, from the meeting with Resident #7 and her family from the week prior. The SW said the meeting was last Monday (12/01/2025) or Tuesday (12/02/2025) with the DON, Resident #7, Resident #7's family, and her. She said the meeting was maybe later than 4 PM. The handwritten note as written, to discontinue the Gabapentin and PRN (as needed) the Tylenol or Tramadol. The medication adjustments per the family requests included a pain patch and brace at night. This surveyor requested the handwritten note to be emailed; the SW said she would email it to the surveyor. The SW said the DON was going to type up the handwritten note since she was a SW and does not do medications. Record review of the SW's hand written note (via screenshot) provided by the ADM and interview on 12/11/2025 at 3:41 PM, the screenshot showed an image of a handwritten note that reflected: [Resident X] - [Resident X room number] - A 4 pm mtg- Med adjustments - family request- Pain patch- w/ brace @ nightuse tramadol or tylenolAt this time, this surveyor requested the original handwritten note to be sent to this surveyor, with the note to discontinue the Gabapentin. The ADM said the note he sent was the note the SW sent to him, indicating it was the original note. This surveyor explained the SW showed a handwritten note stating to discontinue the Gabapentin order; the ADM asked if this surveyor saw the note or had the note, indicating this surveyor did not have proof or see the note mention Gabapentin. This surveyor explained the handwritten note was from a meeting the week prior, and the ADM denied there be a meeting the week prior. He indicated that because he did not initiate the meeting, the meeting did not happen. The ADM refused to give the SW's full handwritten note from the meeting with Resident #7, her family, the DON, and SW. Upon a closer review of the screenshot of the handwritten note, the screenshot revealed the full handwritten note in the camera roll below the partial handwritten note and reflected: [Resident X] - [Resident X room number] - A 4 pm mtg- Med adjustments - family request- Pain patch- w/ brace @ night- DC: gabapentinuse tramadol or tylenol PRNThe full handwritten note showed the discrepancy of DC: gabapentin right above use tramadol or tylenol PRN. During an interview on 12/11/2025 at 5:35PM with the SW, she revealed she wrote the notes for the DON during the meeting in the prior week. She recalled the discussion about the plan for the pain patch, the brace, and Tramadol and Tylenol being prn. When asked if the note said to discontinue the Gabapentin, the SW said, I don't know. When asked to show the handwritten note on her phone again, she said I deleted it, I thought we were done with it. The SW said she did recall discussing Gabapentin in the meeting. She said she did not email the handwritten note because she cannot send it from her personal email. This surveyor asked the SW to look at the screenshot with the full handwritten note and partial handwritten note and to identify the discrepancy. The SW said, Gabapentin is there and Gabapentin is not there. When asked if she knew why there was a discrepancy, she said no. When asked what the risk of records not being kept accurately was, she stated missed information. [NAME] an interview on 12/11/2025 at 5:48 PM with RN C, she identified the discrepancies between the full handwritten note and partial handwritten note. When asked why the discrepancy was an issue, she stated she did not know why the Gabapentin was an issue. She said DONs and nurses take their own notes; she discussed part of nurse's responsibilities include taking their own notes and not having another staff member take notes. RN C stated I have never experienced this, never had this issue before. I didn't see anything. I heard her [SW] say to [the ADM] do I send it to you or work email and [the ADM] said send to me. It's not their character. During an interview on 12/11/2025 at 6:08 PM with the ADM, he was asked what the discrepancies between the full handwritten note and partial handwritten note was and would not verbally state what the discrepancy was. The ADM said, That was there and that wasn't there. I'm repeating myself. He said, whatever was forwarded to me was forwarded to you. When asked why discrepancy was a risk, the ADM said, I don't have an answer for your question because I don't know what risk you are talking about. When asked the what the risk associated with inaccurate records was, he stated That was a voluntary note she provided. I don't know. When asked what the risk was if the partial handwritten note going forward as an order, the ADM stated Ma'am, I don't know if I have an answer.Record review of the facility's Documentation - Nursing policy, date revised 01/2025, reflected: PurposeTo provide documentation of resident status and care given by nursing staff.PolicyNursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrativecharting, as outlined in specific policies and procedures, will be used for initial treatments orprocedures. Documentation for subsequent and/or routine care and procedures may be completedby exception. Checklists, flow charts, and other documentation tools will be used as appropriate.Nursing documentation will not contain error-prone abbreviations.Nursing staff will not falsify or improperly correct nursing documentation.ProcedureI. Nursing DocumentationA. admission nursing assessments completed by individual assessment on the day ofadmission.- If the time required to complete the admission nursing assessment crosses amidnight, the admission is considered completed as of the date and time theassessment was initiated as long as it is completed within 4 hours of that starttime.B. Minimum data set (MDS) completion as per CMS and Medicare guidelines.C. The Licensed Nurse will review the Plan of Care on a weekly basis and document theresident's response and progress towards the goal.D. Any communications with family, durable power of attorney (DPOA), or physician is to benoted in nurse's notes.E. All laboratory data will be dated, timed, and initialed when received and initially reviewedby a licensed.- This notation may be made on the laboratory results page.- The date, time, and signature of the licensed nurse reviewing the laboratory dataand the disposition of that information shall be noted in the nurse's notes.F. Nurse's notes are dated, timed, and signed when written.G. Nurse's notes addressing the resident leaving the facility will document when and withwhom, and time of return, along with any medications sent.H. Medication administration records and treatment administration records are completedwith each medication or treatment completed.I. Glucose measuring is documented as per physician's order.J. Treatments completed and documented as per physician's order.K. Documentation will be completed by the end of the assigned shift.

Based on interview and record review, the facility failed to assure resident assessments were accurate and reflected the resident's current medical status for 1 (Resident #72) of 8 residents reviewed for assessment accuracy. The facility failed to ensure Resident #72 was not misdiagnosed with Type 1 Diabetes Mellitus and the MDS reflected accurate diagnoses. This failure could lead to residents receiving inappropriate treatments based on misdiagnoses, and the facility could receive funds based on inaccurate diagnoses.Findings included: Record review of Resident #72's face sheet revealed an [AGE] year-old woman, admitted on [DATE] with a primary diagnosis of Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (decline in cognitive function). On 10/1/2024, Resident #72 was diagnosed with Type 1 Diabetes Mellitus (chronic autoimmune disease that occurs when the body's immune system attacks and destroys insulin-producing cells in the pancreas, leading to little or no insulin production. Record review of Resident #72's quarterly MDS dated [DATE] revealed Resident #72 had a BIMs (Brief Interview for Mental Status, cognitive assessment tool) of 0 (indication that the resident had severe cognitive difficulties) and an active diagnosis of Diabetes Mellitus. Record review of Resident #72's annual MDS dated [DATE] revealed Resident #72's active diagnoses did not include Diabetes Mellitus.Record review of Resident #72's blood sugar graph, dated 12/1/2023 through 12/10/2025, did not reveal any blood glucose readings. Record review of Resident #72's order summary, dated 12/11/2025, did not reveal active orders for Diabetes Mellitus.Record review of Resident #72's Care Plan, dated 12/11/2025, did not reveal a plan of care for the Type 1 Diabetes Mellitus diagnosis. During an interview on 12/11/2025 at 10:24 AM with LVN G, he stated the only way Resident #72 could have gotten a diagnosis for Type 1 Diabetes mellitus was from a doctor's order for a new diagnosis or if she was at the hospital. He said he put the diagnosis in Resident #72's chart. After reviewing Resident #72's records, LVN G said he could not find anything indicating where the diagnosis came from and that it was an error. He said he got an order to have that diagnosis discontinued today and two MDS' had to be modified. LVN G stated correct diagnoses were important because it was what helped doctors and plan of care; it helps make sure residents were taken care of and get medical and social services. He further stated that a wrong diagnosis can be a risk of wrong orders for residents, and wrong medications could be given. During an interview on 12/11/2025 at 11:21 AM with LVN I, she stated correct diagnoses were important because they need to be right on the MDS, so they (facility) do not receive benefits from it (incorrect diagnosis). She further stated the risk of a wrong diagnosis could be that the doctor would identify Resident #72's was not receiving anything (medication) for diabetes mellitus and go ahead and give Resident #72 metformin (insulin medication). During an interview on 12/11/2025 at 11:57 AM with the RN J, she stated the correct diagnoses were important so that the facility does not get paid for it and get accurate assessments (of residents). She did not think there was a risk of an incorrect diagnosis for Resident #72 since they were not actively doing anything for the diagnosis, and said the risk was minimal if any. RN J said she would hope the doctor questioned the diagnosis before prescribing medication for Type 1 Diabetes Mellitus. Record review of the facility's RAI Process policy, revised 8/22/2024, reflected: PurposeTo ensure that the Resident Assessment Instrument (RAI) is used, in accordance with specified format and timeframes, in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified.III. Each MDS section will be completed by the responsible individual.B. Each resident's assessment will be coordinated by and certified as complete by a registered nurse, and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment he or she completed. C. All information recorded within the MDS Assessment must reflect the resident's status at the time of the Assessment Reference Date (ARD).

Based on observation, interview and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for one of five residents (Resident#3) reviewed for residents' call system. The facility failed on 11/16/25 to ensure the call light system was inaccessible for Resident #3. The call light was out of reach and under the positioning rail. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings included: Record review of Resident #3's face sheet undated reflected Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy (brain dysfunction caused by a systemic illness or metabolic imbalance that affects brain function), glaucoma (group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve) and heart failure. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected Resident #3 had a BIMS of 15 indicating she was cognitively intact. Resident #3 required partial/moderate assistance with ADLs of transfers and toileting. Resident #3 was frequently incontinent of bowel/bladder. Record review of Resident #3's comprehensive care plan reflected Resident #3 revised on 09/24/25 had an actual fall with injury due to poor balance and unsteady gait. Resident #3 is at risk for falls related to gait/balance problems. Intervention included Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observation and Interview on 11/16/25 at 2:13 PM revealed Resident #3 was yelling and calling out from her room for help. There was no facility staff in the hall. Resident #3 was lying in her bed and her call button was under the right positioning side rail. Resident #3 stated she needed help and told surveyor thank you I had no way of getting help other than yelling out. Resident #3 stated she could not use her call button if it was not near her and she needed assistance. She stated she was dependent on staff for assistance and was bed bound. Interview and observation on 11/16/25 at 2:16 PM with Med Aide E revealed Resident #3's call button was not within reach and should have been within reach. Observation revealed Med Aide E moved the call button within reach of Resident #3. Resident #3 stated she needed assistance from a nurse. Interview on 11/16/25 at 2:18 PM with LVN F revealed Resident #3's call button should be within reach of resident to use when she needs assistance from staff. LVN F stated Resident #3 was dependent on staff for assistance. Interview on 11/17/25 at 11:21 AM with DON revealed call buttons should be within reach of residents so they can get assistance and help when needed. She stated the risk to a resident not having a call button within reach could be a delay in getting assistance from staff. Review of facility's policy Communication - Call System last revised June 2020 reflected To provide a mechanism for residents to promptly communicate to nursing staff. The facility will provide a call system to enable residents to alert the nursing staff from their rooms.Call cords will be placed within the resident's reach in the resident's room.'

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 Residents (Resident #1 and Resident #2) observed for infection control. 1.The facility failed to ensure CNA A and CNA B performed hand hygiene during incontinence care to Resident #1 and CNA B failed to perform hand hygiene prior to leaving the resident's room on 11/17/25. 2.The facility failed to ensure CNA C and CNA D performed hand hygiene during incontinence care to Resident #2 on 11/17/25.Findings included: 1. Record review of Resident #1's Face Sheet dated 11/17/25 reflected a [AGE] year-old male with an admission date of 07/26/24. Diagnosis included diabetes, hemiplegia (paralysis on one side of the body), and viral hepatitis (liver inflammation due to viral infection). In an observation on 11/17/25 at 09:35 a.m. CNA A entered Resident #1'room with a gown on. She then put on gloves without performing hand hygiene. Within a few minutes, CNA B entered the room and told her she was there to help. CNA B had put on a gown and gloves prior to entering the room. Both CNAs unfastened the residents brief revealing he had a large amount of bowel movement that had oozed upward into his groin area. CNA B proceeded to wipe down each groin with several wipes changing wipes with each swipe. She then wiped under his scrotum changing the wipes but did not clean his penile shaft or pull back the foreskin to clean the meatus area. CNA B removed her gloves and put on clean gloves without performing hand hygiene. Both staff then rolled the resident onto his side. CNA A then wiped from front to back changing the wipes each time until the bowel movement was removed. CNA B then placed a clean brief under the resident while CNA A changed her gloves but did not perform hand hygiene. Both staff rolled the resident over and the resident stated he did not think they got all of the bowel movement from his groin area. CNA B then used 4 wipes to continue cleaning the bowel movement from his groin area, pushing it downward toward the clean brief. Both staff then fastened the brief. CNA B then changed her gloves but did not perform hand hygiene and assisted CNA A with pulling the resident up in the bed and repositioning. Both staff gathered the trash and removed their gloves. CNA B washed her hands while CNA A left the room with the trash without performing had hygiene. CNA A walked down the hallway to deposit the trash in the soiled linen room. In an interview on 11/17/225 at 10:20 a.m. with CNA B she stated she knew she missed some steps during care. She stated she failed to perform hand hygiene between glove changes. She stated she should have sanitized her hands after cleaning him, before placing the clean brief on him and then pulling him up in the bed. She stated the risk of not performing hand hygiene was infection and possible urinary tract infections. In an interview on 11/17/25 at 11:10 a.m. with CNA A she stated she was supposed to perform hand hygiene before care, after glove changes and before she left the resident's room. She stated she did not do hand hygiene after she changed her gloves and did not wash her hands before she left the room. She stated the risk of not performing hand hygiene were infections and urinary tract infections. 2. Record review of Resident #2's Face Sheet dated 11/17/25 reflected a [AGE] year-old female with an admission date of 09/10/24. Diagnoses included seizures, hemiplegia (paralysis on one side of the body) and mild cognitive impairment. In an observation on 11/17/25 at 10:05 a.m. CNA C and CNA D revealed both staff Resident #2's doorway sanitizing their hands, putting on gowns and gloves. Both staff then entered Resident #2's room to provide incontinent care. Both staff unfastened the residents' brief. CNA C spread the labia and wiped down the middle using one wipe per swipe, wiped across the pubic area and down each groin changing the wipes each time. Staff rolled the resident over and CNA C wiped the resident from front to back. While wearing the same gloves used to provide peri care, CNA C placed a clean brief under the resident and rolled her back and fastened the brief. Staff then repositioned the resident, covered her up still wearing soiled gloves. Both staff then removed their gloves and gowns and washed their hands. In an interview with CNAs C and D on 11/17/25 at 10:10 a.m. both stated they were supposed to perform hand hygiene before incontinent care and once they finished. CNA C then stated she should have also performed glove change and hand hygiene when she finished cleaning the resident, before putting on the clean brief and repositioning her. They both stated the risk of not performing hand hygiene and glove changes was the spread of germs and infections. In an interview with the DON on 11/17/225 at 11:15 a.m. she stated it was the expectation for the staff to perform hand hygiene before care, after each glove change, and before leaving the room. She stated they were also to change their gloves when soiled, before moving to the clean part of care. She stated they would be starting peri-care skills checks immediately as well as hand hygiene training. Record review of the facility's' policy titled, Hand hygiene reflected, .The facility considers hand hygiene the primary means to prevent the spread of infections.Facility staff are trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Facility staff.must perform hand hygiene procedures in the following circumstances.Immediately upon entering a resident occupied area.regardless of glove use.Immediately upon exiting a resident occupied area.Hand hygiene is always the final step after removing and disposing of personal protective equipment.The use of gloves does not replace hand hygiene procedures. Record review of the facility's policy titled, Perineal Care, dated June 2020, reflected, .Put on gloves. Wash the pubic area.Turn resident to side.Remove gloves. Wash hands or use alcohol-based sanitizer. Note: Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, etc.) .Put on clean gloves. Clean and return all equipment to its proper place. Place soiled linen in proper container. Remove gloves. Wash hands.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #1) reviewed for catheter and incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #1 when he failed to pull back the foreskin and failed to clean the resident's penial shaft during incontinence care on 11/17/25. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included: Record review of Resident #1's quarterly MDS assessment, dated 08/29/25, reflected a [AGE] year-old male with an admission date of 07/26/24. He had a BIMS score of 15 which indicated he was cognitively intact. He was dependent on staff for toileting hygiene and was always incontinent of urine and bowel. Diagnosis included diabetes, hemiplegia (paralysis on one side of the body), and viral hepatitis (liver inflammation due to viral infection). Record review of Resident #1's care plan, initiated on 09/10/24, reflected, [Resident #] has bowel and bladder incontinence related to disease process, impaired mobility.Interventions.Check the resident how often 2 hours and as required for incontinence. Wash, rinse and dry perineum (the diamond-shaped area of soft tissue between the anus and the genitals) . In an interview with Resident #1 on 11/17/25 at 09:30 a.m. he stated he was waiting for the CNA to come and change him. He stated he knew he had a bowel movement. He stated they changed him last around 05:00 a.m. In an observation and interview on 11/17/25 at 09:35 a.m. CNA A entered Resident #1's room. CNA A put on a gown and gloves and a few minutes later CNA B entered the room and told her she was there to help. CNA B put on a gown and gloves. Both CNAs unfastened the residents brief revealing he had a large amount of bowel movement that had oozed upward into his groin area. CNA B proceeded to wipe down each groin with several wipes changing wipes with each swipe. She then wiped under his scrotum changing the wipes but did not clean his penile shaft or pull back the foreskin to clean the meatus area (opening in the penis where urine comes out). CNA B removed her gloves and put on clean gloves without performing hand hygiene. Both staff then rolled the resident onto his side. CNA A then wiped from front to back changing the wipes each time until the bowel movement was removed. CNA B then placed a clean brief under the resident and both staff rolled the resident over onto his back. The resident stated he did not think they got all of the bowel movement from his groin area. CNA B then used 4 wipes to continue cleaning the bowel movement from his groin area, pushing it downward toward the clean brief. Both staff then fastened the brief. In an interview on 11/17/225 at 10:20 a.m. with CNA B she stated she knew she missed some steps during care. She stated she did not clean the resident's penis or pull back his foreskin. She stated the risk of not performing proper incontinence care was infection and possible urinary tract infections. In an interview on 11/17/25 at 11:10 a.m. with CNA A she stated the risk of not cleaning the resident penis could cause skin problems as well as infections. She stated they were supposed to clean all of the areas anytime they did incontinence care. In an interview with the DON on 11/17/225 at 11:15 a.m. she stated any time the staff did incontinence care on a male they were supposed to clean the penis and if they were uncircumcised they had to pull the foreskin back to clean around the meatus. She stated failure to do perform correct incontinence care could lead to an increased risk of urinary tract infections. She stated they would be starting peri-care skills checks immediately. Record review of the facility's policy titled, Perineal Care, dated June 2020, reflected, .Put on gloves. Wash the pubic area.For male residents.Wash the penis from the ureteral opening or tip of the penis. Pull back the foreskin on uncircumcised males and clean under it. Wash the scrotum, pay attention to skin folds, rinse and dry.Wash, rinse and dry buttocks and peri-anal area without contaminating perineal area.

Based on observation, interview and record review, the facility failed to ensure staff had successfully completed a State-approved training course for feeding assistance before feeding residents who required staff to feed them, for 1 of 1 residents (Resident #1) reviewed for meal assistance. The facility did not ensure the Social Worker completed a state approved training course for feeding residents before assisting Resident #1 with feeding. This failure could place residents who required assistance with eating at risk of aspiration and choking. Findings included: Record review of Resident #1's admission record, dated 03/20/2025, revealed an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (A neurodegenerative disease primarily affecting the central nervous system affecting both motor and non-motor systems), generalized anxiety disorder, and essential tremor (a neurological condition causing involuntary, rhythmic shaking). Record review of Resident #1's admission MDS assessment, dated 02/13/2025, revealed a BIMS score of 12, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 required supervision with eating. Observation on 03/20/2025 at 1:51 pm, revealed Resident #1 lying in bed. The Social Worker was standing up next to Resident #1's bed, wearing gloves and feeding Resident #1 a tuna sandwich. The Social Worker would bring up the sandwich to Resident #1's mouth and she would take a bite. Resident #1 was observed holding another sandwich with her left hand but was not able to bring her hand up to her mouth. Interview on 03/20/2025 at 2:00 pm, the Social Worker stated his duties included to walk around and see who needed help and he would assist residents with meals if the situation came up. He stated he could not say for sure if he was trained to assist residents with feeding. He stated he wore gloves for health concerns and some residents preferred that they wore gloves. He stated there could be a dignity issue when standing over residents while feeding. The Social Worker stated CNAs usually assisted residents with meals, and he did not assist any other residents with feeding today. Interview on 03/26/2025 at 11:31 am, the Administrator stated CNAs and nurses were trained how to feed as part of their competency. He stated they did general in-services on customer service but no training on how to feed residents. He stated Resident #1 was able to feed herself, and the Social Worker was assisting. He stated all of the department heads had been checked off on checking trays, puree and mechanical diets. The Administrator stated the Social Worker was setting up and not feeding Resident #1. The Administrator stated when the SW brought the food to Resident #1's mouth, it was not considered feeding and the SW was setting up. He stated the risk was an employee not knowing if something was not right with the patient while feeding but it did not apply in this case. Surveyor requested feeding and/or paid feeding assistant policy. Interview on 03/26/2025 at 2:19 pm, the DON stated Resident #1 was normally independent, able to feed herself and the managers could set up the tray for her. She stated the risk if staff were not trained could be choking or giving the wrong diet, but she stated she did not think the SW was feeding Resident #1. The DON stated there was no policy on assisted feeding and normally the skills were taught at school so the CNAs and Nurses were trained already. Record review of the Social Worker's file and training record revealed no state approved feeding training course was taken.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #1) residents reviewed for infection control. RN A and ADON B failed to put on Personal Protective Equipment (PPE) while providing catheter care on Resident #1, who was on Enhanced Barrier Precaution (EBP). RN A failed to perform aseptic technique when performing catheter care for Resident #1. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #1's face sheet, dated 2/20/2025, revealed that Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of acute kidney failure and depression. Review of Resident #1's physician orders, dated 2/13/2025, revealed that EBP should be practiced during care related to indwelling catheter. The order stated that Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: Dressing, Bathing/ Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices like central lines, catheters, feeding tube, tracheostomy/ventilator. Observation on 2/20/2025 at 1:00pm, RN A went in Resident #1's room with a new catheter bag to replace the old catheter bag. There was a sign at the door marking EBP. He performed hand hygiene, did not wear a gown, proceeded to greet Resident #1 to inform him that he was going to change the catheter bag to a new one. He put on gloves, emptied the collection bag in a urinal, and started to remove the old tubing from the catheter port when he was struggling to remove it. He then proceeded to the bathroom to empty the urinal in the toilet and flushed. He removed his gloves, performed hand hygiene, and informed the state surveyor he's going to get a different pair of gloves of his size. He came back in the room, with ADON B, both performed hand hygiene, wore gloves but they did not wear a gown. ADON B assisted RN A in removing the old collection bag tube from the port. RN A attached the new inlet tube to the catheter port without performing aseptic technique, not wiping both the inlet tube and catheter port with alcohol wipe. He discarded the old collection bag in the trash, performed hand hygiene, and left Resident #1's room. In an interview on 2/20/2025 at 1:24pm with ADON B, he confirmed that this resident was on EBP and he stated both he and RN A should have worn a gown before performing the procedure. He stated the risk of not wearing PPE was transmission of infection. He also stated that he came in to help RN A remove the old tubing and he forgot to wear PPE. He did not notice if RN A performed aseptic technique, but he stated an alcohol wipe should be used to wipe the new inlet tube and the catheter port. In an interview on 2/20/2025 at 1:30pm, RN A stated that he forgot to wear a gown while providing catheter care to Resident #1. He also stated he did not wipe the port and the inlet tube with alcohol wipe before attaching the tube to the port. He said the risk of not wearing PPE and performing aseptic technique was transmission of infection. In an interview on 2/20/2025 at 3:00pm, the DON stated that the purpose of wearing PPE while providing care for a resident on EBP was to prevent transmission of diseases and infection. She stated she was shocked to learn that ADON B and RN A did not wear PPE while providing catheter care to Resident #1 because they both have been in-serviced about infection control. She also stated that aseptic technique should be used while providing catheter care and changing catheter collection bag. She stated RN A was supposed to wipe the catheter port and the inlet tube with alcohol wipes before attaching them. Review of facility's Catheter care manual, dated 6/2020, section Collection bag stated that aseptic technique must be used to change the drainage bag. The catheter-tubing junction must be disinfected with an alcohol or chlorhexidine (CHG) sponge prior to connecting the new drainage bag. Review of facility's Standard and Enhanced Precaution Policy, dated April 2024, revealed that Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities . such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers. For residents whom EBP are indicated, EBP should be used when performing high-contact resident care activities such as Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #2) reviewed for comprehensive care plans. Resident #2's care plan did not address the resident's need to receive enteral feeding provided by the facility with goals or interventions. This deficient practice could result in a loss of quality of life due to residents receiving improper care. Findings included: Record review of Resident #2's face sheet, dated 2/20/2025, revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of body) and hemiparesis (one-sided muscle weakness) affecting dominant left side, type 2 diabetes, and acute kidney failure. The resident was discharged from the facility on 2/11/2025. Record review of Resident #2's Admission MDS, dated [DATE], indicated that the resident's nutritional approach while he was a resident of the facility should be via feeding tube. Record review of Resident #2's orders, dated 1/17/2025, revealed that there were orders related to enteral feedings. The orders included providing bolus enteral feeding five times a day, flushing of g-tube, and cleansing of g-tube every shift. There was also an order of NPO (nothing by mouth) dated 1/27/2025. Record review of Resident #2's Comprehensive Care plan, dated 1/17/2025, revealed there was no care plan related to resident's enteral feeding with specific goals and interventions . In an interview with the DON on 2/20/2025 at 3:00pm, she stated that the enteral feeding should be included in the Comprehensive Care Plan. She stated that the IDT met and developed a comprehensive care plan. The DON then will finalize the comprehensive care plan. She stated that a comprehensive care plan was important because everybody can provide care for a resident by looking at it and make sure that a resident received proper care with a detailed care plan. She stated that she was not sure why the enteral feeding was not included in Resident #2's comprehensive care plan. Record review of facility's policy titled Care Planning, dated January 2024, the policy stated that each resident's Comprehensive Care Plan will describe . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive Admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.

Based on interviews and record review the facility failed to develop and implement a baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 4 residents (Resident #1) reviewed for baseline care plans. The facility failed to create a baseline care plan for Resident #1 within 48 hours of admission that addressed the resident's need for indwelling catheter care. This failure could place the resident at risk of infection, a lack of continuity of care and communication among nursing home staff, reduced resident satisfaction of care, and reduced safeguards against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #1 face sheet, dated 2/20/2025, revealed that Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses of acute kidney failure and depression. Review of Resident #1 physician orders, dated 2/13/2025, revealed that there were orders for maintaining indwelling Foley catheter, providing catheter care every shift and as needed. Record review of care plan for Resident #1 on 2/18/2025 revealed no information or interventions about resident's acute kidney failure diagnosis or plan for indwelling catheter care and maintenance . Observation on 2/20/2025 at 1:00pm, RN A went in Resident #1's room to change the catheter collection bag for Resident #1. Resident #1 had a Foley catheter that needed the collection bag to be changed due to the catheter tube appearing cloudy. Interview on 2/20/2025 at 3:03pm with the DON revealed that the baseline care plan should be done within 48 hours after admission. The interdisciplinary team (IDT) including the ADON, the dietitian, the administration, the social worker, the activity director, and the therapy manager were responsible for developing a baseline care plan. The ADON then will review everything and finalize the baseline care plan . The DON said that the risk of not having a baseline care plan was that residents would not be cared for effective and had their needs met. Review of the facility's Care Planning policy, dated January 2024, revealed that the purpose of a care plan was to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. It also stated that: The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will include at least the following information: A. Initial goals based on admission orders B. Physician orders C. Dietary orders D. Therapy services E. Social services F. PASARR recommendations, if applicable

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and only authorized personnel have access to the keys for 1 (Medication Cart and Medication Cart Keys on RH #1400) of 3 medication carts reviewed for storage of medication. LVN N failed to ensure that medication cart keys and drawers were secured before walking away from the cart on RH #1400. This failure could place residents at risk of overdosing, theft of medication cart keys, and drug diversion. Findings included: In an observation on 01/14/2025 at 1:15 PM, a medication cart was observed unlocked on RH #1000 with the red button extended indicating it was not locked, and the medication cart keys lying on top of the cart. There was not a facility staff with the cart and keys. At 1:18 PM the SSD was observed walking toward the surveyor and medication cart. The surveyor asked who was the authorized staff that was in possession and control of the medication cart and keys. The SSD searched and found out that LVN N was the assigned staff to the medication cart. LVN N was located by SSD in resident room [ROOM NUMBER]. In an interview with LVNN on 01/14/25 at 2:05 PM, she stated she was called to assist a CNA with a blood sugar patient, and this distracted her, and she forget to lock the cart and take the keys. She stated she has never left an unlocked medication cart and keys exposed before. LVN N stated it was important for the medication cart to be locked when unattended and the keys in her possession (in her pocket) to prevent staff, visitors, and residents from accessing resident medications, blood sugar machines, sharp objects, and preventing drug diversions. She said the risk of leaving the medication cart unlocked with the keys on top, could lead to patient's accessing medication, missing keys, and resulting in a negative or adverse reactions causing harm. In an interview with the DON on 01/14/25 at 2:58 PM, revealed it was her expectation that all authorized staff lock the medication cart and keep the keys on them at all times before walking away. The risk of failing to lock the medication cart and secure medication keys, could lead to theft of medication, theft of keys, resident missed medication, uncertified staff, visitors, and residents from having access to the medications and supplies located inside the cart. She stated the potential harm to residents include medication overdose, have an allergic reaction, and possible adverse reaction. The DON stated it was the responsibility of the DON and ADON to monitor and audit medication cart security and safety at the facility. In interview with the ADM on 01/14/25 at 3:11 PM revealed it was his expectation for all authorized medication staff to secure medication cart, lock, and keep keys with them at all times to prevent drug diversions, resident, staff, and visitors from accessing. He said the potential medication drug carts left unsecured, patient take self-administering, adverse allergic reactions, and other life-threatening incidents. In a record review of facility policy titled Storage of Medication dated 09/2018 reflected Medications and biologicals are stored safely, securely, and properly, following manufacturer' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two of three residents (Resident #127 and Resident #56) reviewed for abuse, neglect, and exploitation. 1. The facility failed to provide timely transportation for Resident #127 when he was finished with his medical appointment, being wheelchair bound, offsite from the facility. On 9-10-2024 Resident #127 was not picked up by a transportation driver for over 4 hours causing him to miss his lunch meal, pain medication time for Tramadol PRN every 4 hours (which the resident could have received at 11:00 AM but did not), causing psychosocial harm (resident was crying and felt abandoned which was exacerbated due to the resident's post-traumatic stress disorder). 2. The facility failed to provide timely transportation for Resident #56 on 09-09-2024 due to the van lift malfunction and required his appointment to be rescheduled. The facility failed to provide timely transportation for Resident #56 on 09-10-2024 and was approximately an hour late for his appointment. A IJ was identified on 9-11-2024. The IJ template was provided to the facility on [DATE] at 3:33 PM. While the IJ was removed on 9-11-2024, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for neglect causing pain, mental anguish, or emotional distress. Findings included: Review of Resident #127's face sheet dated 9-11-2024, reflected the resident was a [AGE] year-old male with an admitted [DATE]. His diagnoses include fracture of the left femur (a break in the left thighbone), anxiety disorder, type 2 diabetes, PTSD (a mental disorder that develops in some people who have experienced a shocking, scary, or dangerous events), COPD (lung disease making it difficult to breath), and a history of falling. Record review of Resident #127's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate mental impairment. Resident #127's functional abilities revealed he required Substantial/maximal assistance (where the helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort) from a sitting position to a standing position and not attempted due to medical condition or safety concerns to car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Review of Resident #127's Care Plan dated 9-11-2024 indicated he was at risk for skin breakdowns causing redness, blisters, bruises, discoloration, was care planned for pain management stating to anticipate Resident #127's need for pain relief and respond immediately, was on psychotropic medication for PTSD, and had wound management which encouraged Resident #127 to elevate his legs to be free of infection. Review of Resident #127's MAR revealed Resident# 127 was ordered for pain management PRN every 4 hours for Tramadol oral tablet and Tylenol 2 tablets. In an observation on 9-10-2024 at 1:30 PM, Resident #127 was entering the facility, being pushed in a wheelchair, by a family friend in an upset mood. The family friend #1 pushed Resident #127 into his bedroom. In an observation and interview on 9-10-2024 at 1:37 PM, it was revealed, by family friend #1, that Resident #127 just returned from his doctor's appointment because the transportation driver never returned to pick Resident #127 up when his appointment was completed. Family friend #1 said he was very upset with the facility. Family friend #1 stated Resident #127 finished his appointment at the orthopedic surgeon's office at 9:15 AM, the doctor's staff called Driver B to pick up Resident #127 at 9:15 AM, and by 1:09 PM no one had come to pick Resident #127 up. Family friend #1 said after waiting for hours Resident #127 began to get upset, get hungry, and cry because no one had come to pick him up. Family friend #1 said Resident #127 started getting weak sitting in his wheelchair for so long that he started to slide out of it. Family friend #1 said he then called Resident #127's Family Member #1 at 1:09 PM to let her know the situation. Family friend #1 said he was told by Resident #127's Family Member #1 to transport Resident #127 back to the facility as this was ridiculous for no one to come in over 4 hours to pick Resident #127 up. In an observation and interview on 9-10-2024 at 3:08 PM, Resident #127 was lying in his bed tilted up in a 45-degree angle and said he was kept waiting at his doctor's office today for over 4 hours after his appointment was completed. Resident #127 began crying and was visibly upset saying he felt abandoned by the facility. Resident #127 said he felt pain while he was waiting to be picked up as he dealt with psoriasis over his entire buttocks area and between his legs in his crouch area. Resident #127 said his pain level got to a level 10 while waiting to be picked up. Resident #127 said when he sat for long periods of time it made his psoriasis affected areas painful. Resident #127 stated his normal pain level was a 0. In an interview with Resident #127's Family Member #1 on 9-10-2024 at 3:10 PM it was revealed that the driver never came back to the doctor's office to pick up Resident #127 this morning for over 4 hours. Resident #127's Family Member #1 said she paid family friend #1 to keep Resident #127 company when she could not be with Resident #127 because she worked on a job. Resident #127's Family Member #1 said family friend #1 does not transport Resident #127 but the facility does. Resident #127's Family Member #1 said after Resident #127 waited for over 4 hours to be picked up he became upset, started feeling weak, got in pain, and was hungry. Resident #127's Family Member #1 said after a 4 hour wait, she asked family friend #1 if he would bring Resident #127 back to the facility. Resident #127's Family Member #1 said this has happed before on medical appointments but could not name specific times. In an interview on 9-10-2024 at 2:05 PM the Transportation Manager revealed she has worked at the facility since 12-2023. The Transportation Manager said the facility use to outsource driving residents but due to budget cuts and unreliable service, the facility uses 1 van and 2 inhouse drivers. The Transportation Manager said the facility brought residents to their medical appointments including dialysis. The Transportation Manager said transportation has been a problem since she has worked at the facility because the nursing staff haven't had the residents dressed on time or haven't had the necessary paperwork ready, and the facility only has one van servicing the entire facility. The Transportation Manager said the reason Resident #127 wasn't picked up this morning for 4 hours, after his appointment was finished, was that Driver B was picking up and dropping off other residents. The Transportation Manager said the concern for residents who are not picked up from their appointments timely was that some of them could have been diabetic or have other medical problems they may have needed help with. She stated that the facility tried to outsource transportation for Resident #127 but the resident would have to wait longer. The Transportation Manager said in her opinion the facility needed more transportation vehicles and drivers to meet the demand of the facility. The Transportation Manager said the facility did not keep a transportation log of when residents arrived at appointments nor when they were picked up from the facility. The Transportation Manager said she was told by the Administrator to not outsource any driving for the facility due to budget cuts. Resident #56 also had an appointment with an orthopedic. In an interview with the Orthopedic Doctor's Office Staff for Resident #127 on 9-10-2024 at 4:53 PM, it was revealed that Resident #127 completed his medical appointment on 9-10-2024 at 9:12 AM and the staff called Driver B, at that time, to pick up Resident #127. The Orthopedic Doctor's Office Staff for Resident #127 said they made a 2nd call to Driver B at 10:26 AM telling her Resident #127 was ready to be picked up. The Orthopedic Doctor's Office Staff for Resident #127 said at 11:50 AM Driver B called them saying she was on her way to pick up Resident #127. In an interview with Driver B on 9-11-2024 at 11:10 AM, it was revealed she has worked at the facility since 8-14-2024. Driver B said there was only 1 van and 2 drivers for the entire facility. Driver B said the facility does not provide a facility phone to keep in touch with the facility, the doctor's office, or the residents. Driver B said the reason she was so late in picking up Resident #127 yesterday was because the facility had her going to so many appointments for other residents, she could not pick Resident #127 up timely. Driver B said she did not get back to Resident #127's location to around 1:00 PM. Driver B said picking up residents for their medical appointments and bringing them back to the facility has been a problem since she has worked at the facility. Driver B said the concern for residents being picked up late from their appointments was when they sit so long there could be potential health risk as they may be feeling weak from dialysis appointment or may need something to eat. In interview with Driver B on 09/11/2024 at 11:07 AM she stated that she left late for Resident #56's appointment because Resident #56 was not ready when she arrived to transport him. She stated this was an ongoing issue that she has reported to her the Transportation Manager. She stated that Resident #56's appointment was at 9:15 AM but she was not able to leave the facility until 9 or 10 AM and returned Resident #56 to the facility around 11 AM. She stated that Resident #56 was late to his appointment but was seen by the doctor. In interview with Driver A on 09/13/2024 at 8:48 AM, he stated that it was his first day on the job on 09/09/2024. He stated that he recalled leaving the facility with Resident #56 to transport him to his appointment around 2:30 PM that day. He stated that he could not get the lift to lower at the doctor's appointment and called DRIVER B to trouble-shoot. He stated it took too long and Resident #56's Family Member #3 had to reschedule his appointment. He stated that Resident #56's Family Member #3 had a right to be mad about missing his appointment. He stated it was important for residents at the facility to be at their appointments timely for resident care. 2. Review of Resident #56's Face Sheet, dated 09/11/2024, revealed he was a [AGE] year-old male readmitted to the facility from an acute care hospital on 08/27/2024. Relevant diagnoses included right femur fracture (bone break,) cerebral infarction (disrupted blood flow to the brain,) hypertension (high blood pressure,) type 2 diabetes (insulin resistance,) and history of falling (result of gravity (from vertical to a horizontal position with gravitational force considerations.) Review of Resident #56's Comprehensive Care Plan, dated 09/10/2024, revealed he had an ADL Self Care Performance Deficit related to debility and required partial/moderate assistance for transfers. He was at risk for falls and had a fall without injury on 09/01/2024. Additionally, Resident #56 had diabetes and required medication and monitoring for side effects and effectiveness. Resident #56 had a potential risk for skin breakdown, had occasional forgetfulness, and was on anticoagulant therapy. Review of Resident #56's Admission MDS dated [DATE] revealed he was severely cognitively impaired and had a BIMS score of 06. He was dependent where helper does all the effort for car transfers and required partial/moderate assistance for toileting. No current or prior device aids (wheelchair, lift, walker, etc) were documented. In interview with Resident #56 and his Family Member #3 on 09/10/2024 at 4:31 PM he did not recall specifics of his transportation and asked me to defer to his Family Member #3 for information. In an interview with Resident #56's Family Member #3 on 09/10/224 at 4:31 PM she stated that she has had transportation issues on 09/09/2024 and 09/10/2024. She stated on 09/09/2024, he missed his appointment because the wheelchair van lift malfunctioned, and he was not able to get out of the van on time to make his appointment. She stated on 09/10/2024 he was an hour late to his appointment and almost missed that appointment, but the doctor was nice enough to take him late. She stated she was infuriated that she cannot depend on the facility to take Resident #56 to his appointments on time. She stated that Resident #56's dementia had progressed so much he cannot keep track of his own schedule and she needs to trust the facility to reliably take him to his appointments for his overall healing and wellbeing. In an interview with facility Transportation Manager on 09/10/2024 at 4:38 PM she stated she was not sure about the specifics of Resident #56's transportation information and requested to review her documentation. In interview with facility Transportation Manager on 09/11/2024 at 10:36 AM she stated that on 09/09/2024 the transportation driver for Resident #56 was Driver A, but it was his first day on the job. She stated that Resident #56 successfully was loaded into the van, but Driver A had issues getting Resident #56 out of the van once they arrived at the doctor's office. She stated the resident's appointment was missed and had to be rescheduled for a later date. She stated on 09/10/2024 the transportation driver was Driver B. She stated that she was aware that Driver B ran behind yesterday but was not sure of the specifics. She stated she was not authorized by the Administrator to use third party transportation because of costs but having only one van was not cutting it. Record review of the facility's Abuse and Neglect Policy dated 10-24-2022 stated: Purpose - To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property . III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems . Procedure III. Training A. Covered individuals will be trained through orientation and on-going training sessions, no less than annually, on the following topics: i. Who is a covered individual responsible for reporting ii. Abuse prevention iii. Identification and recognition of signs and symptoms of abuse/neglect iv. Protection of residents during an abuse investigation v. Investigation vi. Reporting and documentation of abuse and neglect without fear of reprisal . Prevention B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring . E. The Facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met . Identification ii. Physical Neglect a. Malnutrition and dehydration (unexplained weight loss) b. Poor hygiene c. Inappropriate clothing (soiled, tattered, poor fitting, lacking, inappropriate for season) d. Decayed teeth e. Improper use/administration of medication; f. Inadequate provision of care g. Caregiver indifference to resident's personal care and needs h. Failure to provide privacy. i. Leaving someone unattended who needs supervision . iii. Possible Signs and Symptoms of Psychological Abuse or Neglect a. Resident clings to caregiver/abuser b. Paranoia . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults . H. Appropriate professional and licensing boards will be notified when a Facility Staff member is found to have committed abuse, neglect, or mistreatment of residents. On 9-11-2024 at 3:30 PM, the Administrator and the DON were notified that an Immediate Jeopardy had been identified concerning Resident #127 not being picked up for over 4 hours away from the facility. The Administrator stated he did not know anything about it. The IJ template was provided to the facility on [DATE] at 3:33 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 9-12-2024 at 11:48 AM and reflected the following: F600 On 9/11/2024 during a Full book survey at [Facility Name] at [Facility Address]. HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to provide services. Facility failed to provide transportation from MD appointment back to facility in a timely manner, Resident#127 was left for 4 hours at a doctor's appointment without transportation back to facility, resulting in the resident missing regular mealtimes, and experiencing psychosocial harm. The notification of the alleged immediate jeopardy states as follows: Resident #127 was left for four hours at a doctor's appointment without transportation back to the facility, resulting in the resident missing pain medication, not meeting regular mealtimes, and experiencing psychosocial harm. Identify residents who could be affected. All residents who go out on scheduled appointments and are transported via facility transportation have the potential to be affected. Identify responsible staff/ what action taken. 1. Director of Nurses/Administrator and ADON re-educated by the Regional Clinical Nurse on the facility policy on abuse/neglect and resident rights. With a completion date of 9/11/2024. 2. DON/ADON's educated by Regional Clinical Nurse on procedure for patients out on appointments which includes follow up if resident is out of facility on MD appointment greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With completion date of 9/11/2024 3. All licensed nurses RN and LVN educated by DON/ADON's on Abuse/neglect, resident rights, change in condition, and procedure for patients out on appointments which includes follow up if resident is out of facility on MD appointment greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With completion date of 9/11/2024 4. Training for all licensed nurses RN and LVN's, follow up for patients out on MD appointment by DON/ADON's with completion date of 9/11/2024. 5. All licensed staff RN/LVN in serviced on use of transportation log, which will be at every nursing station. Completion date of 9/11/2024 6. Facility driver and transportation coordinator educated on the following procedural change by Administrator. Facility driver to immediately notify transportation coordinator if unable to pick up resident/patient from appointment within an hour. The coordinator will immediately schedule with alternate vendor for immediate pick up/drop off. The Transportation coordinator will immediately notify Administrator/Director of Nursing/ Assistant Director of Nursing of the status of patient. Completion by 9/12/2024 7. All staff in-serviced on abuse/neglect, resident rights by administrator/DON with completion date of 9/11/2024. 8. Resident # 127 head to toe assessment completed by RN with no adverse findings. Pain assessment, skin assessment, trauma assessment all completed with no adverse findings. Social worker followed up with patient and no adverse findings. Primary MD, [Physician] notified. All completed on 9/11/2024. In-Service conducted. 1. Director of Nurses/Administrator and ADON re-educated by the Regional Clinical Nurse on the facility policy on abuse/neglect and resident rights. With a completion date of 9/11/2024. 2. DON/ADON's educated by Regional Clinical Nurse on procedure for patients out on appointments which includes follow up if resident is out of facility on MD appointment greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With completion date of 9/11/2024 3. Facility driver and transportation coordinator educated on the following procedural change by Administrator. Facility driver to immediately notify transportation coordinator if unable to pick up resident/patient from appointment within the hour. The coordinator will immediately schedule with alternate vendor for immediate pick up/ drop off. The transportation coordinator will immediately notify Administrator/ Director of Nursing of the status of patient. Completion date 9/12/2024. 4. All licensed nurses RN and LVN educated by DON/ADON's on Abuse/neglect, resident rights, change in condition, and procedure for patients out on appointments which includes follow up if resident is out of facility on MD appointment greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With completion date of 9/11/2024 5. Training for all licensed nurses RN and LVN's, follow up for patients out on MD appointment by DON/ADON's with completion date of 9/11/2024. 6. All staff in-serviced on abuse/neglect, resident rights by administrator/DON with completion date of 9/11/2024. 7. All licensed staff in-serviced on use of transportation log, which will be at every nurse's station, with completion date of 9/11/2024. Implementation of Changes Director of Nursing, Assistant Director of Nursing/Administrator re-educated on facility policy on abuse/neglect and resident rights by Completed on 9/11/2024 by Regional Nurse Consultant Director of Nursing, Assistant Director of Nursing educated by Regional Clinical Nurse on procedure for patients out on MD appointments which includes follow up if resident is out of facility on MD appointment greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With completion date of 9/11/2024. Facility driver and transportation coordinator educated on the following procedural change by Administrator. Facility driver to immediately notify transportation coordinator if unable to pick up resident/patient from appointment within the hour. The coordinator will immediately schedule with alternate vendor for immediate pick up/ drop off. The transportation coordinator will immediately notify Administrator/ Director of Nursing of the status of the patient. Completion dated 9/12/2024. All Licensed staff RN, LVN educated by Director of Nursing/Assistant director of Nursing on procedure for patients out on MD appointments, which includes follow up if resident is out of facility greater than 3 hours, Nurse is to call MD office to follow up to ascertain patient status. With Completion date of 9/11/2024. All licensed staff in-serviced on transportation log, to be kept at every nurse's station. The changes were started by the Regional Nurse Consultant. The changes were implemented effective on 9/11/2024 and training to be completed on 9/12/2024. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on Abuse/neglect, resident rights, and procedure for patients out on MD appointments, which includes follow up if patient is out greater than 3 hours, Nurse to call MD office to follow up and ascertain patient status, prior to working the floor. The Director of Nursing will ensure competency through signing of in service, verbalization of understanding and completion of transportation log. The Director of Nursing will complete an audit of all outside appointments daily x 30 days then weekly thereafter. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will be responsible for monitoring the implementation and effectiveness of in-service on 9/11/2024. The Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all outside MD appointments and follow up daily x4 weeks, then weekly thereafter and report any adverse finding during QAPI. Director of Nursing/Assistant Director of Nursing will conduct a daily audit of transportation to outside appointments daily x4 weeks, then weekly thereafter and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 9/11/2024 and conducted an Ad HOC QAPI regarding ensuring patients transferred back to facility from outside appointment in timely manner. The Medical Director was notified about the immediate Jeopardy on 9/11/2024, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 9/11/24. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 9/11/2024. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 9/11/2024. Monitoring the facilities Plan of Removal included the following: In an interview on 9-12-2024 at 10:30 AM, it was revealed that LVN C had worked at the facility for [AGE] years on the 6:00 AM to 2:00 PM shift. LVN C said she was in-serviced on transportation which covered keeping a special log for resident's name, time of appointment, time of pickup from the appointment, who the doctor was, and what was the resident seeing the doctor for. LVN C said the charge nurses would be responsible to ensure the residents are dressed, have their medications, have their paperwork for their appointments, and have eaten breakfast. LVN C stated the nurses would also enter this information in PCC. LVN C stated if a resident has not returned within 3 hours of leaving the facility, the nurse would contact the doctor's office to see if the appointment is finished and then would contact the driver to be picked up. LVN C said the potential risk to a resident, not being picked up timely, was It could be a potential for a lot of things such as they could be diabetic, they could get tired and may be a fall risk, and there could be incidents in the van or at the doctor's office. LVN C said the charge nurses would oversee the tracking of transportation and would make entries into Nursing Notes in PCC. In an interview on 9-12-2024 at 10:50 AM, LVN D said she had worked at the facility for 3 months on the 6:00 AM-2:00 PM shift and had been in-serviced on transportation. LVN D said the in-service included: the incident concerning Resident #127, the nurses were responsible for documenting in the transportation log when residents leave for appointments and put the information into PCC. LVN D stated if a resident was transported and gone for over 3 hours, the nurses were to call the doctor's office to see if the resident has been seen. LVN D stated the nurses were responsible the residents were tracked getting to an appointment and returning to the facility. LVN D said the risk to the resident not being timely transported was they could miss a treatment, appointments, and cause them not to get medicines on time. In an interview on 9-12-2024 at 11:00 AM, LVN E revealed she had worked at the facility for 6 years and was working the 6:00 AM - 2:00 PM shift. LVN E said she had been in-serviced on transportation. LVN E said there were new protocols put in place as the nurses were to check the transportation schedule and see what residents were on the schedule for that day. LVN E said there was a paper log where nurses enter patients name, destination, time of appointment, how the resident transports (stretcher, wheelchair, walk), and if the driver was from the facility or outsourced. LVN E said that the nurses were to call the doctor's office to see if there was a hold up or if the resident was waiting to be picked up. LVN E said the nurses will call the dialysis facility if a resident was over an hour late in getting back to the facility. LVN E said the risk to residents that were not picked up timely from appointments could be their blood sugar dropping, not getting medicines on time, and not getting fed. LVN E said the nurses were the primary ones to keep track of appointments by entering it into a paper transportation log and into PCC. LVN E said if a resident is over 30 minutes to an hour late getting back to the facility, she will check on them. In an interview with the DON on 9-12-2024 at 11:25 AM revealed the DON was in-serviced on transportation follow-up and what to educate the nurses on by following up and keeping track of the resident's appointments. The DON said now they have a monitoring tool in the transportation log. Resident's name, who is transporting, what time the resident is leaving and what time they return. The DON said to ensure this type of neglect does not happen again the facility has been sent a 2nd van to help with the transportation workload. The DON stated the DON, ADON, and Administrator will oversee monitoring the licensed nurses for effective follow-up. The DON stated the reason Resident #127 being left for over 4 hours at a medical appointment, without being picked up, was an IJ was complacency. The DON said she was just blown away with it. In an interview with the Administrator on 9-12-2024 at 11:40 AM it was revealed he was in-serviced by the Corporate Nurse to make sure facility van drivers notify the Transportation Manager when they are running an hour late or more, in picking up a resident, so the Transportation Manager can notify an outsourced driving service. The Administrator said he was in-serviced on abuse, neglect, resident rights, and a decision was made that licensed nurses have been trained in completing a transportation log when a resident has not returned from a medical appointment within 3 hours of leaving the facility. The Administrator said the DON and the ADONs would oversee the licensed nurses to ensure residents were followed up on when being transported. The Administrator said the reason this IJ was called was because the State alleged a resident was not picked up from a doctor's appointment, after the appointment was over, for 4 hours. The Administrator said the facility does not have a transportation policy. In an interview with the Transportation Manager on 9-12-2024 at 12:45 PM reflected the new protocol for was more communication between the drivers and the facility. The Transportation Manager stated if a resident was going to be more than one hour late to an appointment the driver will notify the Transportation Manager who in turn would notify the nurses who work the hallway where the resident lives in. After that, the Transportation Manager said the nurses notify the DON, ADON, and the Administrator. The Transportation Manager said to ensure resident were not left waiting for long periods of time, after an appointment is finished, the facility will call the residents on their cell phones and the nurses will follow-up with the residents.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #48) of seven residents observed for infection control. The facility failed to ensure Resident #48's foley bag was not lying on the floor detached from the bed. This failure could affect residents and place them at risk of illness and exposure to diseases. Findings include: Record review of Resident #48's Face Sheet dated 9-13-2024 reflected an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of [NAME] Nile Virus (a neurological disease contracted from mosquitoes causing headache, body aches, joint pains, vomiting, diarrhea, or rash) with Encephalitis (a serious condition that causes the brain to swell due to inflammation), Enteropathogenic Escherichia Coli Infection (a bacterial pathogen that adheres to intestinal epithelial cells, causing diarrhea), and Myocardial Infarction (heat attack). Record review of Resident #48's MDS revealed a BIMS score of 4 indicating severe cognitive impairment. Resident #48's functional abilities of his MDS revealed his that his toileting hygiene: (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement .) which indicated he was a code of 1 (Dependent - Helper does all the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #48's care plan dated 9-13-2024 stated Resident #48 has an indwelling Foley Catheter 16FR 10cc bulb to bedside drainage Catheter: Obstructive Uropathy (a structural or functional hindrance of normal urine flow) .and to Check tubing for kinks and maintain the drainage bag off the floor. In an observation and interview on 9-10-2024 at 12:15 PM, Resident #48 was observed lying in bed with an indwelling catheter and the foley bag attached lying flat on the floor. Resident #48 said he did not know the foley bag was on the floor and he cannot control his bowel or bladder movement. Resident #48's Family Member #2 said she had been in Resident #48's bedroom for 45 minutes and the foley bag has been on the floor the entire time. In an observation and interview on 9-10-2024 at 12:25 PM LVN C was shown Resident #48's foley bag lying flat on the floor. LVN C said that is not good and left the room and came back wearing protective gloves to provide infection control and reattach the foley bag. In an interview on 9-10-2024, LVN C revealed she has worked at the facility for [AGE] years. LVN C said the concern for foley bags being on the floor was that it was an infection control issue, and it should not be on the floor. LVN C stated she works the hallway that includes Resident #48. In an interview on 9-10-2024 at 1:16 PM CNA K said the problem with a catheter foley bag being on the floor was that it was on the floor. CNA K said she did rounds to ensure foley bags were not on the floor. CNA K said if she would have walked in and saw a foley bag on the floor she would have told a charge nurse. In an interview on 9-13-2024 at 3:00 PM, the DON revealed her expectations were that foley bags be kept off floors. The DON said it was the nursing staff's responsibility to ensure foley bags are kept off floors, but the CNAs can pick them up. The DON said the potential risk to residents having an attached foley bag was infections, germs, and stuff. Record review of the facilities Catheter Care Policy dated 6-2020 reflected the following: Catheter - Care of Nursing Manual - Nursing Care Policy No. - NP - 260 Confidential and Proprietary Information. Purpose: To prevent catheter-associated urinary tract infections while ensuring that residents are not given in dwelling catheters unless medically necessary. Policy I. Each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible . Procedure: III. Proper Techniques for Urinary Catheter Maintenance D. Urinary Flow-an unobstructed flow of urine should be maintained. In order to achieve a free flow of urine: i. Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor .

Based on interview, observation, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident' choices for one (Resident #1) of five resident reviewed for wound care. LVN B failed to follow physician orders to complete wound care for Resident #1's and apply calcium alginate to the surgical wound to his right ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone). This failure could place residents at risk for a deterioration in the condition of their wounds. Findings included: Review of Resident #1's Face Sheet, dated 08/15/23, revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses quadriplegia, acquired absence of unspecified leg above knee, contracture of left and right hands, diabetes, urinary tract infection, and post-traumatic stress disorder. Review of Resident #1's Quarterly MDS assessment, dated 07/27/23, reflected the resident had a BIMS score of 15 which indicated he was cognitively intact. The Quarterly MDS assessment reflected Resident #1 received surgical wound care. Review of Resident #1's Care Plan dated 08/15/23 reflected, the resident had an actual impairment to his skin integrity related to right ischial flap surgery. The Care Plan reflected; Resident #1 received wound management for the surgical wound to his right ischium. Care plan interventions included: Continue to encourage Resident #1 to allow wound care as ordered and administer treatments per treatment order and notify physician of resident refusals. Review of Resident #1's physician wound treatment orders and treatment administration record dated 07/21/2023 reflected cleanse right ischium with normal saline/wound cleanser, pat dry, apply Calcium Alginate, and cover with dry dressing Monday, Wednesday, Friday, and PRN if soiled or dislodged. In an interview on 08/15/2023 at 9:56 AM Resident #1 stated he had a skin injury to his bottom. Resident #1 stated the dressing was changed to his bottom on 08/14/23 by a nurse at 5:30 AM. Resident #1 stated his wound was supposed to be packed with something inside of the wound but none of the staff place anything inside of his wound and just place a dressing over top of his wound. In an interview on 08/15/23 at 10:14 AM with the facility wound care nurse LVN A stated she asked the charge nurse LVN B on 08/14/23 to change Resident #1s wound dressing on the 2:00 PM to 10:00 PM shift because it was the shift Resident #1 received his shower and the time in which his wound dressing would be changed. LVN A stated she asked LVN B to change the wound dressing for Resident #1 to ensure the resident did not have a wet dressing after his shower. An observation on 08/15/23 at 10:18 AM LVN A obtained permission from Resident #1 to observe the dressing to his right ischium. LVN A and the Director of Rehab entered resident room washed their hands with soap and water and donned gloves. LVN A along with assistance of the Director of Rehab assisted Resident #1 to a side lying position exposing his right hip. The dressing to Resident #1's right hip appeared clean dry and intact, the dressing had no date or initials indicating when or who performed the dressing change. LVN A removed the wound dressing covering Resident #1's right ischium and stated after inspection of the resident's wound there was nothing packed inside the wound. Resident #1 stated every nurse comes to him to provide wound care and placed a sticker on top of his wound and do not pack anything inside of it and because they do not pack anything inside of it his wound will not heal. LVN A disposed of the dressing and her gloves and washed her hands with soap and water, returned to her wound care cart and prepared wound care supplies to provide wound care to Resident #1's right ischium. LVN A verified the wound treatment order for Resident #1, using disinfectant wipe disinfected resident bedside table and allowed it to dry. LVN A sanitized hands her hands with ABHR, placed a wax paper on the bedside table as a barrier between the wound care supplies and bedside table. LVN A then took the bedside table with wound care supplies and placed it near Resident #1's bed. LVN A washed her hands with soap and water, donned gloves, assessed Resident #1's pain, resident stated he was in no pain. LVN A wound care nurse informed Resident #1 of each step of care before the care was provided. LVN A with assistance of Director or Rehab who cleansed her hands with soap and water and donned gloves positioned the resident on his side. LVN A using a measuring device and q-tip applicator measured the resident wound length, width and depth. LVN A disposed of the q-tip applicator measuring device and gloves in biohazard bag, sanitized her hands with ABHR, and donned new gloves. LVN A cleansed resident wound bed with soaked gauze and q-tip applicator, disposed of supplies and gloves, and sanitized her hands with ABHR. LVN A donned new gloves and with saline soaked gauze cleansed the resident's wound outer edges and surrounding skin, disposed of supplies and gloves and washed her hands with soap and water. LVN A donned new gloves, used a q-tip applicator told resident she was going to pack calcium alginate into his wound bed, and then packed a calcium alginate dressing strip into the resident's wound bed. LVN A disposed of supplies and gloves, sanitized her hands with ABHR, and donned new gloves. LVN A applied a dated 08/15/23, initialed, and clean gauze adhesive bordered dressing to cover wound and secure in place the calcium alginate packed into the wound bed. LVN A disposed of gloves and remaining supplies and washed hands with soap and water before leaving the resident's room. In an interview on 08/15/23 at 11:15 AM LVN A stated when she was unavailable to perform wound are facility charge nurses like LVN B are provided access to the wound care supplies and trained in providing wound care to residents. LVN A stated facility nurses were aware of the treatment to be provided a wound by reviewing the physician wound orders and the facility treatment administration record. LVN A stated it was important to follow physician orders related to the treatment of a resident's wound because it could impact the healing of the wound, she stated calcium alginate would be necessary to help with drainage from a wound. LVN A stated following wound treatment orders could help heal the wound and not following wound orders could be detrimental to the healing of the wound. LVN A stated she had been providing wound care for Resident #1 since June of 2022. LVN A stated the wound to Resident #1's right hip had been present on his admission; he has had several skin flap surgeries to his sacral area. LVN A stated she this morning she assessed Resident #1's dressing and wound before performing wound care and his wound was clean, the dressing removed had minimal serous drainage, the dressing removed was not initialed or dated, there were no foul odors associated with the drainage noted, and there were no secondary dressings packed into Resident #1's wound. LVN A stated Resident #1 told her it was the charge nurse LVN B on the 2pm-10pm shift who applied the dressing to his right ischium that was not packed with calcium alginate. LVN A stated based upon her assessment of Resident #1's wound was stable, there was no noted deterioration. LVN A stated should she notice deterioration of Resident #'1 wound she would notify his wound care physician. LVN A stated she had not had to report and deterioration of Resident #1's wound to the wound care physician. LVN A stated with previous wound treatments when removing Resident #1's wound dressing she had not noticed any other instance where components of his wound dressing were not present, or the dressing not initialed or dated. LVN A stated the wound care physician sees Resident #1 each Monday when he allows her to visualize his wound the physician had not voiced any concerns regarding the healing of his wound. LVN A stated the wound care physician had commented Resident #1 would potentially have the wound to his ischium for life due to multiple flap surgeries with some failure to completely heal the wound to his right ischium. LVN A stated the risk to Resident #1 should his wound care orders not be followed as prescribed his wound could become infected or increase in size and or pain. In an interview on 08/15/23 at 12:09 AM LVN B stated she worked the 2:00 PM to 10:00 PM shift on 08/14/23 and provided wound care to Resident #1. LVN B stated as charge nurse she had access to the wound treatment supplies and knew what treatment to provide a resident by reviewing eh physician order for a resident in their electronic chart. LVN B stated after providing wound care for a resident she would document a progress note in the electronic medical record the treatment was done. LVN B stated when she provided wound treatment to Resident # 1's right ischium she dated the dressing. LVN B stated 08/14/23 she could not find the calcium alginate and did not use it to pack his wound. LVN B stated she normally used calcium alginate to treat Resident #1's wound and when she could not find the calcium alginate on the wound cart she did not look anywhere else or called anyone to tell them she could not find the calcium alginate. LVN B stated the risk of not providing wound care and not applying calcium alginate to Resident #1's wound was it could delay his healing. In an interview on 08/15/23 at 11:56 AM Resident #1's wound care physician stated the resident had a chronic wound to his right ischium which she suspected would not heal due to ischemia (inadequate blood flow to that part of the body) and without another plastic surgery it would remain on his right ischium. The wound care physician stated the wound to Resident #1's right ischium had been stable, there had been no note deterioration to his wound and should there be facility staff would communicate any changes to his wound to her. The wound care physician stated Resident # 1 had not communicated to her in the past any concerns with facility staff not providing wound care per her treatment orders. The wound care physician stated when she has removed his dressings and assessed his wounds the dressing she has observed were dated, initialed, his wounds have not macerated (grow thinner or waste away) or deteriorated and she believed Resident #1's wound care had been provided per her physician orders. In an interview on 08/15/23 at 2:06 PM the DON stated in event the wound care nurse LVN A was unable to provide a resident wound care the facility charge nurses like LVN B were to provide resident's wound care. The DON stated wound care supplies are located at each nursing station and should a nurse be unable to find a wound care supply on the treatment cart they should check central supply and or pick up the phone and contact either her or LVN A to be directed where to find supplies. The DON stated she expected a nurse who provided wound care treatments to follow physician orders located in the resident's electronic medical record and treatment administration record. The DON stated should wound care orders not be followed by staff as prescribed it could risk wound deterioration and infection to a resident. The DON stated when staff perform a wound dressing change, she expected staff to date and initial the dressing to show accountability the treatment was completed as well as document the treatment in the resident's treatment administration record and or resident's electronic progress note. The DON stated LVN B did not call her 08/14/23 to indicate she was not able to find wound care supplies to perform Resident #1's wound treatment and the facility was not out of calcium alginate required to perform the resident's wound treatment. The DON stated LVN B should have initialed and dated the wound dressing she applied to Resident #1's right ischium to indicate it was changed by her. The DON stated LVN B should have also documented in the resident's treatment administration record or nurse progress note the treatment had been provided. The DON stated Resident #1 had a long-standing chronic wound to his right ischium with the wound care physician monitors each week on Mondays. The DON stated the wound care physician with her assessment of his wounds had not voiced to her any concerns regarding infection of Resident #1's wound and his wound had been a chronic stable wound. The DON stated Resident #1 had been to several appointments regarding his wound, but the surgical wound had not completely closed. Review of the wound care physician's progress notes dated 07/27/23 reflected Resident #1's right hip surgical wound was not healed with 0.2cm length, 0.8cm width x 1 cm in depth. Review of facility skin wound noted dated 08/15/23 reflected Resident #1's surgical wound to his right ischium measured 0.3 cm length, 0.8cm width x 1 cm in depth. Review of LVN B's facility Clinical Competency Validation for Wound Dressing: Aseptic dated 06/02/23 reflected critical elements 1. Verifies order and reviews skin Integrity report .30. Documents patient response to treatment, wound evaluation, treatment administration. Review of Resident #1's Treatment Administration Record and progress notes dated 08/14/23 revelaed no record of LVN B provided wound care treatment to Resident #1's right ischium. Review of facility policy titled, Wound Management revised 06/20, reflected Purpose: To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury. Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing .Procedure: I. Assessment: .B. Upon identification of a new wound the Licensed Nurse will: .ii. Initiate a Wound Monitoring Record sheet; .c. The Wound Monitoring Record is optional for recording skin tears, lacerations, cuts, and abrasion. If the Wound Monitoring Record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans. iii. Implement a wound treatment per physician's order . Review of facility policy titled, Medication Administration not dated, reflected .XIX. Documentation: A. The time and dose of the drug or treatment administered to a resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication and or type of the treatment. C. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record .

Based on interview and record review the facility failed to submit a discharge MDS assessment for two of four residents (Resident #90 and Resident #108) reviewed for timely MDS submission. The MDS Coordinator failed to successfully submit a discharge MDS assessment for Resident #90 and Resident #108 when they discharged from the facility. This failure could place residents at risk of communication about a resident's status from not being transmitted to CMS and could interfere with residents receiving needed services after discharge. Findings include: Record review of Resident #90's face sheet, dated 08/07/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE]. Resident #90 had diagnoses which included Parkinson's Disease (Brain and Nervous System Disease); Type 2 Diabetes Mellitus without Complications (High levels of sugar in the blood); and Hypertensive Heart Disease (Constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). Record review of the Discharge Instructions for the Care document for Resident #90, dated 04/28/23, reflected he was discharged to an Assisted Living Facility. Resident #90 was under the care of Veterans Administration contact. All discharge needs (Primary Care Physician, Durable Medical Equipment, and Home Health) were set up through the VA. There was a home health provider on file . Resident's Primary Care Physician was documented, and Durable Medical Equipment ordered was a wheelchair. Record review of Resident #90's EMR on 03/29/23 reflected a 5-day MDS assessment, marked accepted on 03/29/23. Resident #90 discharged on [DATE]. No discharge MDS was completed. Record review of Resident #108's face sheet, dated 08/07/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE]. Resident #108 had diagnoses which included muscle wasting and atrophy (decrease in size and wasting of muscle tissue); malignant neoplasm of prostate (disease of malignant cancer cells form in the tissues of the prostate); other and unspecified ventral hernia with obstruction, without gangrene (protrusion of contents of the abdominal cavity through abdominal wall, without mention on necrosis of the herniated content). Record review of nursing progress notes dated 04/04/23 revealed Resident #108 discharged from the facility and was sent to theER on [DATE]. The nursing progress notes revealed resident #108's family member notified the facility of transfer to the ER from the Oncologist Office. Resident #108 did not return to the facility. Record review of Resident #108's EMR, dated 02/09/23, reflected a 5-day MDS assessment, marked accepted on 02/09/23. The Quarterly MDS assessment, was marked accepted on 03/03/23. Resident #108 discharged from the facility on 04/04/23. No discharge MDS assessment was completed. Interview on 08/04/23 at 12:22 PM, with the MDS Coordinator revealed Resident #90's and Resident #108's names did not have the discharge MDS's completed. The admission and discharge date s were provided. The MDS Coordinator reviewed the MDS's for both residents. The MDS Coordinator returned and revealed she did not complete the discharge MDS's. The MDS Coordinator stated she missed completing them . Record review of the RAI Process policy, from the facility's Operational Manual - Administrative Policies with no revision dates, did not specifically address discharge MDS. The policy reflected the following under Documentation Storage. When a resident is discharged return anticipated and does not return within 30 days or is discharged return not anticipated, the previous admission's RAI will not be copied to the new clinical record. Record review of the Chapter 2: The Assessment Schedule for the RAI, Revised 12/02, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MinimumDataSets20/Downloads/RAI-Manual-Chapter-2.pdf reflected A Discharge-return not anticipated .is completed when it is determined that the resident is being discharged with no expectation of return after a comprehensive Admission assessment has been completed. A discharge with return not anticipated can be a formal discharge to home, to another facility .

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Resident #1) of 7 residents reviewed for medication administration. The facility failed to ensure Resident #1's blood sugars were monitored and insulin administered as ordered by his physician. These failures affected former Resident #1 and could affect other residents, who received insulin, by placing them at risk of complications and decline in their health from not receiving medications as ordered by the physician. Findings included: Record Review of Resident #1's Admission Record dated [DATE] indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a chemical imbalance of the brain), diabetes (high blood sugars), and heart disease. He expired on [DATE]. Record Review of Resident #1's quarterly MDS dated [DATE] indicated, the resident was severely cognitively impaired. He had a diagnosis of non-traumatic brain dysfunction. He required extensive assistance from one to two staff for transfers, and bed mobility. He was not ambulatory. He was always incontinent of bowel and bladder. He received all of his nutrition, and hydration from his feeding tube. Record Review of Resident #1's Care Plan dated [DATE], cancel date for the care plan, indicated the resident had a diagnosis of diabetes, the goal was for the resident to have no complications related to his diabetes. The interventions included to administer his diabetic medications as ordered by the doctor and monitor/document for side effects and effectiveness. The interventions also included, to monitor for signs and symptoms of high blood sugar, such as, weight loss, fatigue, stupor, and coma. Record Review of Resident #1's Physician Order dated [DATE] indicated: Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units greater than 401 give 10 units, notify MD, and recheck in one hour, subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Record Review of Resident #1's General Progress Note dated [DATE] at 2:13 PM indicated, the resident was awake and sitting in a Geri chair watching television at nurses' station with enteral nutrition flowing. He had spoken several words to staff. Record Review of Resident #1's Nutrition/Weight Note dated [DATE] at 3:46 PM indicated, the resident had lost 6.3% body weight in 30 days and 15.9% in 90 days. The RD gave a recommendation to change the resident's enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid in the form of a tube feeding) from Glucerna to Jevity (enteral nutrition formulas). A physician's order was obtained for the change. Record Review of Resident #1's Physician Order dated [DATE] indicated: Enteral Feed Order every shift Jevity 1.5 @ 75 ml/hour x 22 hour to provide 2475 calories and water flush at 50 ml/hour concurrently to provide add 1100 ml fluid for hydration needs. Record Review of Resident #1's Nurse Administration Record dated [DATE] - [DATE] indicated: Enteral Feed Order every shift Jevity 1.5 @ 75 ml/hour x 22 hour to provide 2475 calories and water flush at 50 ml/hour concurrently to provide add 1100 ml fluid for hydration needs. Record Review of Resident #1's General Progress Note dated [DATE] at 2:30 PM indicated the resident blood sugar was 599. The NP was in facility and gave an order for LVN A to administer 10 units of insulin and recheck in one hour, which was done. After rechecking, the resident's blood sugar was 499. The NP was notified again, and she gave an order to administer 10 units of insulin and increase fluids. The resident given 120 ml bolus and the enteral nutrition continued. There was no document the resident's blood sugar was rechecked after the second 10 units of insulin was administered. Record Review of Resident #1's eMar - Medication Administration Note dated [DATE] at 10:13 AM, indicated: Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: if 151 - 200 = 2 units 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units 351 - 400 = 10 units greater than 401 give 10 units, notify MD, and recheck in one hour, subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS LVN A notified the NP the resident's blood sugar was 511, 10 units were given with 240 ml bolus water flush. There was no documentation the resident's blood sugar was rechecked in one hour after the 10 units were administered. Record Review of Resident #1's General Progress Note dated [DATE] at 10:10 PM, indicated the resident was admitted to Hospice services related to his diagnosis of heart disease. His current medications were continued. Record Review of Resident #1's Physician Order dated [DATE] indicated: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Record Review of Resident #1's General Progress Note dated [DATE] indicated, at 7:23 AM the resident's Insulin Glargine Subcutaneous Solution 100 UNIT/ML Inject 12 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS was changed from 12 units two times a day to 15 units two times a day related to the resident's high blood sugar level. At 7:25 AM, the resident had signs and symptoms of high blood sugar. The glucometer (a device to measure blood sugar) did not register a blood sugar number but registered HI (according to the glucometer, a reading of HI meant the resident's blood sugar was over 600). The NP was notified of the blood sugar registering HI on glucometer and gave an order to hold the resident's enteral nutrition, administer water flushes and increase the resident's long-acting insulin (Insulin Glargine Subcutaneous Solution 100 UNIT/ML) from 12 to 15 units. There was no documentation resident's blood sugar was rechecked after the glucometer reading was HI. There was no physician's order entered into the electronic medical record to change the resident's Glargine insulin from 12 to 15 units. Record Review of Resident #1's Nurse Administration Record dated [DATE] - [DATE] indicated: Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS was administered at 6:30 AM and 4:30 PM on [DATE], [DATE], [DATE], [DATE], [DATE], instead of the 15 units ordered on [DATE]. Record Review of Resident #1's eMar - Medication Administration Note dated [DATE] at 8:37 AM, indicated: Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: if 151 - 200 = 2 units 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units 51 - 400 = 10 units greater than 401 give 10 units, notify MD, and recheck in one hour, subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS The resident's blood sugar was 441 and the NP gave an order to administer 10 units. There was no documentation the resident's blood sugar was rechecked in one hour after the 10 units were administered. Record Review of Resident #1's Medical Practitioner Note dated [DATE] at 12:08 PM indicated, the resident had significant weight loss over the past two months and his enteral nutrition had been changed. He had a clinical decline. His hemoglobin AIC (a test to measure blood sugar control) on [DATE] was 7.5 (the goal for adults with diabetes was less than 7, according to the American Diabetes Association, diabetes.org) and was to be checked again in [DATE]. The resident was on Hospice and his long-term prognosis was poor. Record Review of Resident #1's General Progress Note dated [DATE] at 2:31 PM, indicated the resident was declining, unresponsive. His enteral nutrition was on hold. Record Review of Resident #1's eMar - Medication Administration Note dated [DATE] at 7:36 AM, indicated: Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: if 151 - 200 = 2 units 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units 51 - 400 = 10 units greater than 401 give 10 units, notify MD, and recheck in one hour, subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS LVN A notified the NP the resident's blood sugar was 412. The NP ordered to give the resident 10 units of sliding scale insulin. There was no documentation the resident's blood sugar was rechecked in one hour after the 10 units were administered. Record Review of Resident #1's General Progress Note dated [DATE] at 12:09 PM indicated, staff alerted the nurse the resident's mouth was opened and he looked as if he had expired. This nurse assessed resident and no pulse was felt. The ADON was notified. The RN was notified and came to assess resident and was able pronounce. Hospice was notified. In an interview on [DATE] at 9:29 AM, the DON reviewed Resident #1's Nurse Administration Record for [DATE]. She said on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], when the resident's blood sugar was over 401 at 6:30 AM, on those days, there was no documentation the resident's blood sugars were rechecked every hour until they were below 401. She said she expected the nurses to recheck the resident's blood sugars and notify the NP or MD until the resident's blood sugar was less than 401 and document in the progress notes. She said blood sugars in excess of 401 could result in coma or death. In an interview on [DATE] at 10:17 AM, LVN A said, after Resident #1's enteral nutrition was changed from Glucerna to Jevity his blood sugars began to spike. She said she discussed the resident's high blood sugars with the NP. She said the NP gave her an order to change Resident #1's long-acting insulin (Insulin Glargine) from 12 to 15 units on [DATE], but she forgot to put the order change on the Nurse Administration Record, so from [DATE]-[DATE] (5 days) the resident was still getting 12 units instead of the 15 units that were ordered. She said when she worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] and the resident's blood sugar was over 401 at 6:30 AM on those days, she notified the NP and rechecked the resident's blood sugar until it was less than 401. She said she took personal notes of the rechecks of the resident's blood sugars and failed to document them in the electronic medical record. She said she shredded her personal notes at the end of her shift and did not have them to review. She said she should have documented before the end of her shift. She said she notified the NP each time the resident's blood sugar was over 401 by text message, but she did not keep the text messages. She said with blood sugars as high as Resident #1's, over 401, it could lead to a stroke, or the resident could pass away. In a telephone interview on [DATE] at 11:03 AM, the NP said she was aware of Resident #1's high blood sugars, she said the Jevity was not an ideal enteral nutrition formula for residents with diabetes because it could elevate the residents' blood sugars. She said her goal was to see if Resident #1 could gain weight on the new formula and see if his blood sugars would level out. She said when she was made aware of how high the resident's blood sugars were, she ordered an additional 10 units of sliding scale insulin and increased his long-acting insulin from 12 units to 15 units. She said she believed the resident's death was caused by an undiagnosed condition, such as a malignancy. In a telephone interview on [DATE] at 12:09 PM, Resident #1's Primary Physician said he received a call from the resident's night nurse, RN B. He said he could not remember the date, but it was after 9:00 PM. He said she called and let him know the resident's blood sugars had been high. He said the resident's blood sugars were way too high to remain on the Jevity enteral nutrition formula. He said he gave RN B an order to change the formula from Jevity back to Glucerna. He said high blood sugars were damaging to the body; however, Resident #1's high blood sugars were not the cause of his death. According to the American Diabetes Association (diabetes.org), un-treated high blood sugar can lead to diabetic coma, which is life-threatening and needs immediate treatment. In an interview on [DATE] at 1:54 PM, the DON said there was no documentation in Resident #1's clinical record of the communication between RN B and the MD. She said she did not know the date of the call and the MD did not have a record of the call. She said the resident's enteral feeding formula was never changed back to Glucerna. She said the order changes were missed and there was no excuse. She said the nursing administration staff monitor 24-hour reports and have a morning clinical meeting, but the changes were missed and just did not get done. She expects the nursing staff to document by the end of the shift or do a late entry the next day. In an interview on [DATE] at 3:47 PM, RN B said on the night of [DATE] around 11:00 PM she was making rounds and decided, as part of her nursing assessments, to check Resident #1s' blood sugar, it registered HI on the glucometer. She said a HI reading meant the resident's blood sugar was over 600. She said she informed the resident's Primary MD , and he gave an order for 10 units of sliding scale insulin and to change the enteral nutrition formula from Jevity back to Glucerna. She said she administered the 10 units of sliding scale insulin but became ill during her shift and did not enter the order to change for the enteral nutrition formula into the electronic medical system and did not document the communication with the MD, or the additional 10 units of sliding scale insulin that was administered. She said the resident expired the next day on [DATE]. Record Review of the facility's Telephone Orders for Medication policy dated [DATE] indicated the receiver documents the order immediately to reduce errors misinterpreted verbal or telephone communication of physician orders.

Based on interviews and record review, the facility failed to ensure a resident who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral nutrition including metabolic abnormalities for 1 (Resident #1) of 3 residents who were reviewed for enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid in the form of a tube feeding). The facility failed to ensure Resident #1's physician order enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid in the form of a tube feeding) was changed, per the physician's order, to treat high blood sugars. This failure effected former Resident #1 and could place residents who required enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid in the form of a tube feeding) at risk of not receiving necessary treatment and services to prevent complications. Findings included: Record Review of Resident #1's Admission Record dated [DATE] indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a chemical imbalance of the brain), diabetes (high blood sugars), and heart disease. He expired on [DATE]. Record Review of Resident #1's quarterly MDS dated [DATE] indicated, the resident was severely cognitively impaired. He had a diagnosis of non-traumatic brain dysfunction. He required extensive assistance from one to two staff for transfers, and bed mobility. He was not ambulatory. He was always incontinent of bowel and bladder. He received all of his nutrition, and hydration from his feeding tube. Record Review of Resident #1's Care Plan dated [DATE], cancel date for the care plan, indicated the resident had a diagnosis of diabetes, the goal was for the resident to have no complications related to his diabetes. The interventions included to administer his diabetic medications as ordered by the doctor and monitor/document for side effects and effectiveness. The interventions also included, to monitor for signs and symptoms of high blood sugar, such as, weight loss, fatigue, stupor, and coma. The resident had the potential for nutritional problems and received enteral nutrition and hydration. The intervention was for the resident to maintain adequate nutrition. The interventions included, to administer the feedings as ordered by the MD . Record Review of Resident #1's General Progress Note dated [DATE] at 2:13 PM indicated, the resident was awake and sitting in a Geri chair watching television at nurses' station with enteral nutrition flowing. He had spoken several words to staff. Record Review of Resident #1's Nutrition/Weight Note dated [DATE] at 3:46 PM indicated, the resident had lost 6.3% body weight in 30 days and 15.9% in 90 days. The RD gave a recommendation to change the resident's enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid in the form of a tube feeding) from Glucerna to Jevity (enteral nutrition formulas). A physician's order was obtained for the change. Record Review of Resident #1's Physician Order dated [DATE] indicated: Enteral Feed Order every shift Jevity 1.5 @ 75 ml/hour x 22 hour to provide 2475 calories and water flush at 50 ml/hour concurrently to provide add 1100 ml fluid for hydration needs. Record Review of Resident #1's General Progress Note dated [DATE] at 2:30 PM indicated the resident's blood sugar was 599. The NP was in facility and gave an order for LVN A to administer 10 units of insulin and recheck in one hour, which was done. After rechecking, the resident's blood sugar was 499. The NP was notified again, and she gave an order to administer 10 units of insulin and increase fluids. The resident given 120 ml bolus and the enteral nutrition continued. Record Review of Resident #1's General Progress Note dated [DATE] at 10:10 PM, indicated the resident was admitted to Hospice services related to his diagnosis of heart disease. His current medications were continued. Record Review of Resident #1's General Progress Note dated [DATE] indicated, at 7:23 AM the resident's Insulin Glargine Subcutaneous Solution 100 UNIT/ML Inject 12 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS was changed from 12 units two times a day to 15 units two times a day related to the resident's high blood sugar level. At 7:25 AM, the resident had signs and symptoms of high blood sugar. The glucometer (a device to measure blood sugar) did not register a blood sugar number but registered HI (a reading of HI meant the resident's blood sugar was over 600). The NP was notified of the blood sugar registering HI on glucometer and gave an order to hold the resident's enteral nutrition, administer water flushes and increase the resident's long-acting insulin (Insulin Glargine Subcutaneous Solution 100 UNIT/ML) from 12 to 15 units. Record Review of Resident #1's General Progress Note dated [DATE] at 2:31 PM, indicated the resident was declining, unresponsive. His enteral nutrition was on hold. Record Review of Resident #1's General Progress Note dated [DATE] at 12:09 PM indicated, staff alerted the nurse the resident's mouth was opened and he looked as if he had expired. This nurse assessed resident and no pulse was felt. The ADON was notified. The RN was notified and came to assess resident and was able pronounce. Hospice was notified. In an interview on [DATE] at 10:17 AM, LVN A said, after Resident #1's enteral nutrition was changed from Glucerna to Jevity ([DATE]) his blood sugars began to spike. She said on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident's blood sugar was over 401 at 6:30 AM. She said she discussed the resident's high blood sugars with the NP. In a telephone interview on [DATE] at 11:03 AM, the NP said she was aware of Resident #1's high blood sugars, she said the Jevity was not an ideal enteral nutrition formula for residents with diabetes because it could elevate the residents' blood sugars. She said her goal was to see if Resident #1 could gain weight on the new formula and see if his blood sugars would level out. She said she believed the resident's death was caused by an undiagnosed condition, such as a malignancy. In a telephone interview on [DATE] at 12:09 PM, Resident #1's Primary Physician said he received a call from the resident's night nurse, RN B. He said he could not remember the date, but it was after 9:00 PM. He said she called and let him know the resident's blood sugars had been high. He said the resident's blood sugars were way too high to remain on the Jevity enteral nutrition formula. He said he gave RN B an order to change the formula from Jevity back to Glucerna. He said high blood sugars were damaging to the body; however, Resident #1's high blood sugars were not the cause of his death. Record Review of Resident #1's Nurse Administration Record dated [DATE] - [DATE] indicated: Enteral Feed Order every shift Jevity 1.5 @ 75 ml/hour x 22 hour to provide 2475 calories and water flush at 50 ml/hour concurrently to provide add 1100 ml fluid for hydration needs. The enteral nutrition was never changed back to Glucerna, as ordered by the physician. In an interview on [DATE] at 1:54 PM, the DON said there was no documentation in Resident #1's clinical record of the communication between RN B and the MD. She said she did not know the date of the call and the MD did not have a record of the call. She said the resident's enteral feeding formula was never changed back to Glucerna. She said the order changes were missed and there was no excuse. She said the nursing administration staff monitor 24-hour reports and have a morning clinical meeting, but the changes were missed and just did not get done. She expects the nursing staff to document by the end of the shift or do a late entry the next day. In an interview on [DATE] at 3:47 PM, RN B said on the night of [DATE] around 11:00 PM she was making rounds and decided, as part of her nursing assessments, to check Resident #1s' blood sugar, it registered HI on the glucometer. She said a HI reading meant the resident's blood sugar was over 600. She said she informed the resident's Primary MD, and he gave an order for 10 units of sliding scale insulin and to change the enteral nutrition formula from Jevity back to Glucerna. She said she administered the 10 units of sliding scale insulin but became ill during her shift and did not enter the order to change for the enteral nutrition formula into the electronic medical system and did not document the communication with the MD, or the additional 10 units of sliding scale insulin that was administered. She said the resident expired the next day on [DATE]. Record Review of the facility's Tube Feeding policy dated [DATE] indicated, to ensure that the facility met the nutritional guidelines and resident's nutritional requirements per the physician's orders.