Every finding on record at Bel Air at Teravista

Based on observation, interviews, and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards or practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 (Resident # 128) residents reviewed for pain management. The facility failed to administer pain medication to Resident #128, who had pancreatic cancer, from the time she was admitted [DATE] at 7:30 p.m. to 6/2/26 at 10:00 a.m. This failure could place the residents at risk of delayed healing, physical, mental, and psychological distress.Findings included: Record review of Resident #128's face sheet, dated 06/03/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neuroendocrine tumors (pancreatic cancer), secondary malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct (a network of tiny, branching tubes located inside the liver), and pain. Record review of Resident #128's base line care plane, dated 06/01/2026, reflected a focus: Pain management (acute/chronic) with interventions : assess for presence of pain at frequent routine intervals and before/after specific activities and If is unable to self-report pain, discuss pain management history with family/caregiver, observe for behaviors that may indicate pain (rubbing, moaning, crying, guarding, withdraw, agitation), review clinical condition for contributory factors and review any psychological factors that may play a role in pain management. Record review of Resident #128's admission MDS, dated [DATE], reflected an assessment of pain at admission: Resident #128 reported pain in coccyx area (last bone at the base of spine) with Resident #128 was able to communicate pain level: 3/10 (mild pain. An observation and interview of Resident #128 on 06/02/2026 at 11:05 a.m. revealed Resident #128 appeared to be sleepy closing her eyes while talking and showed some discomfort when Resident #128's Family member attempted to reposition her in bed. She stated she was ok and was not able to give more details regarding her pain level or condition. During an interview on 06/02/2026 at 11:05 a.m. Resident #128's Family member reported that Resident #128 did not receive any pain medications from 7:30 p.m. last night when she was admitted to the facility from the hospital until 10 a.m. on 06/02/2026. Resident #128's Family member stated she could have brought Resident #128's pain medication from home sooner had she known the nursing facility would not be able to provide the pain medication as prescribed. Resident #128's Family member stated Resident #128 was crying in pain this morning when she woke up and that was when the facility reported they did not have Resident #128's pain medication. Resident #128's Family member stated she went home at 9:00 a.m. and brought Resident #128's pain medication from home because the facility was unable to provide the prescribed pain medications. She stated Resident #128 frequently required Dilaudid overnight as the pain was worse overnight. Resident #128's Family member reported that Resident #128 told her that she was in pain and when she repositioned her in bed she was complaining of pain. She stated that when Resident #128 was admitted last night, after transferring and moving her from the ambulance stretcher to facility's bed caused her a lot of discomfort and she asked nurses for pain medication before 9:00 p.m. She stated that she was told that pain medication should be delivered from the pharmacy soon. She stated that RN B administered trazodone which helped Resident #128 fall asleep and sleep some of the night, but RN A did not check on Resident #128 to see if she was ok or needed anything else for pain. She stated that she was told again that medications did not come in the morning and that when she went to get Resident #128's pain medication from home because Resident #128's pain was getting worse and it would be hard to get it back to the tolerable level even though Resident #128 had a high pain tolerance level. Record review of physician orders, dated 06/01/2026, revealed Resident #128 was on scheduled and PRN pain medications: fentanyl transdermal patch (a potent transdermal opioid used to manage severe, chronic pain that requires around-the-clock medication) q72hrs 50 mcg/hr, Hydromorphone HCl (Dilaudid) (a potent, semi-synthetic opioid analgesic [narcotic] derived from morphine. It is used to manage moderate-to-severe acute and chronic pain-typically when other treatments were ineffective or cannot be tolerated) Oral Tablet 8mg PRN, give 1.5 tablets (12mg) by mouth every 3 hours as needed for pain related to pain and Naproxen oral tablet 500 mg: give 1 tablet by mouth two times a day related to pain, pregabalin oral capsule 100mg: give 1 capsule by mouth three times a day related to pain. Record review of Resident #128's medication administration record, dated June 2026, revealed that Resident #128 did not receive Hydromorphone HCl oral tablet 8 mg 1.5 tablet by mouth on 06/01/26 and 06/02/2026 until 10 a.m. Resident #128 received Trazodone HCl oral Tablet 50 mg on 06/01/2026 at 9:00 p.m. (for depression and sedation). Naproxen Oral tablet 500 mg was not administered on 06/01/2026 at 9:00 p.m. and administered 1st time on 06/02/2026 Pregabalin oral capsule 100mg was not administered on 06/01/2026 at 9:00 p.m. and administered on 06/02/2026 at AM. Record review of Resident #128's pain assessment revealed on 06/02/2026 at 03:57 am - 7/10 documented by RN A and 9:48 am - 9/10 documented by RN C. There were no interventions provided for the high pain levels reported until 10:00 a.m. when RN C asked Resident #128's Family member to bring Resident #128's home pain medications until they receive their pain medication from the pharmacy. Resident #128's Family member brought pain medications from home and RN C administered Dilaudid 12 mg to Resident #128 which provided the pain relief and resident was able to relax. Record review of Resident #128's progress notes, dated 06/01/2026 at 10:17 p.m. and signed by RN B, revealed [Resident #128] admitted to facility post hospitalization related to altered mental status and acute on chronic pain. Resident arrived at facility about 7:30 p.m. in stretcher accompanied by EMT, with daughter following behind them. No progress nursing notes by RN A on 06/01/26-06/02/2026 with recorded attempts to request pain medications for Resident #128 were identified in Resident #128's medical records. Record review of Resident #128's progress notes, dated 06/02/2026 at 6:59 a.m. signed by RN C, revealed that [Resident #128's] Lyrica, Dilaudid, fentanyl patch and naproxen are not here. Phoned on call pharmacy to ask if they have a script or not, on call pharm took the information for missing meds and said someone will call me back. Also notified NP. Resident #128 currently has fentanyl patch to left upper arm dated 6/1/26. Resident #128's Family member at bedside. During an interview with RN C on 06/02/2026 at 11:05 a.m., she stated that she assessed Resident #128 this morning around 7 a.m. and she was not in pain and was sleeping. She stated that at 9:38am she assessed Resident #128 and she was in pain 9/10. She stated that when she spoke to Resident #128's Family member, she told her that they don't have Resident's Dilaudid available at the facility and Resident #128's Family member offered to bring this medication from home and when she did, it was administered to Resident #128 at 10:00 a.m. RN C stated that she received the report about residents on her hall from the night shift nurse, RN A, in the beginning of her shift, 6:00 a.m. She stated that Resident #128 had orders for pain medication on discharge from the hospital. She stated that she called the on-call provider and the pharmacy requesting medications. She stated that all charge nurses, including night nurses, were responsible for calling on call providers if medications were not available at the facility and residents were in pain. She stated that when she asked RN A about Resident #128's pain medications, she told her that she did not call providers and did not request any new orders for pain relief because she thought her orders already were in the pharmacy and they should send those medications in the morning. She stated that nothing was done last night and she was doing everything this morning: contacted the provider and trying to get Resident #128's medications. She talked to Resident #128's Family member who stayed overnight at the bedside and suggested to bring home medications while they were waiting for the facility's pharmacy to deliver ordered medications. She messaged NP K to get new orders for pain management. She stated that if the pain was not treated, Resident #128 could be in excruciating pain due to her diagnosis of cancer. During an interview with RN A on 06/02/2026 at 1:31 p.m., she stated she worked at this facility for a few months on night shifts 10 p.m. - 6 a.m. She stated that charge nurses were responsible for entering new orders on the system for newly admitted residents. She stated that Resident #128 was admitted on evening shift around 7 p.m. with RN B. She stated that she asked Resident #128's RP if she brought medications from the hospital and she said she did not. RN A stated that RN B told her that there were no medications and Dilaudid were available at pyxis (a secure, automated medication dispensing system) and they checked together. She stated that Resident #128 was in pain during her shift as Resident #128's Family member told her. She stated that when she assessed Resident #128, she was sleeping and did not have grimaces indicating pain, but when Resident #128's Family member asked Resident #128, she said that she was in pain. Resident #128 did not receive her ordered pain medication on her shift, but she gave Resident #128 the ordered trazadone which helped her to fall asleep. She stated that Resident #128's medications did not come from the pharmacy, and this resident did not receive pain medication on her shift. She stated that according to the change of condition protocol, charge nurses should call on call providers, but she did not call because that resident already had orders and she just got here at the end of the evening shift. She stated that her orders had been processed and nothing could be done, just wait until next morning. She stated that nobody explained to her how to get medication from the emergency kit. She stated that she did not contact the on-call provider as she thought this resident could not get another order if she already had the orders in place. She stated that she could not get a different order because the on-call provider could not proscribe anything else if this resident already had pain medication orders. She stated that the unmanaged pain could cause discomfort to residents. During an interview with RN B on 06/02/2026 at 1:53 p.m., she stated that she worked on 6/1/2026 from 2-10pm. She stated that according to the policy for new admissions, she assessed Resident #128, confirmed her ordered medication that were already entered in the system by ADON and verified with NP K, and she explained the medication administration schedule to resident and family. She stated that she received a report from the hospital nurse regarding Resident #128's diagnoses and she was aware that Resident #128 received the medications for chronic pain. She did not ask about pain level at discharge and the hospital nurse did not ask RN B what pharmacy medications should be sent to for Resident #123. She stated that she assumed that medications would be sent to the facility's pharmacy. RN B asked Resident #128 about pain during admission assessment, and she told her that she had pain in coccyx area, but no painful expression was observed during her assessment. She stated that she found out that Dilaudid was not in the pyxis when RN A asked to check if Dilaudid was there. They did not call the pharmacy as she was leaving, but per facility's protocol if medications were not available at the facility charge nurses were responsible for calling the pharmacy and on call physician to get new orders as needed. RN B stated that if pain was not managed properly, residents' condition could decline. During interview with ADON on 06/04/2026 at 11:08 a.m., she stated that she was working at the facility for 12 years as infection preventionist. She stated that she was responsible for communicating with case workers at the hospital and entering new medical orders in the computer system and communicating those orders to providers to get approvals. She stated that she received the discharge hospital orders for Resident #128 approximately an hour before her admission on [DATE] and entered her medication orders in the computer. She stated that she received those orders by e-mail, sent them to NP K for verification and received her approval for those medical orders. She stated that she left on 06/01/2026 PM and was not informed that Resident #128 did not have pain medications available at the facility. She stated that charge nurses were responsible for admitting residents, assessing them, and calling the facility's pharmacy to get medication orders filled and request different medications from on call providers that are available during nighttime if medications were not available at the facility. She stated that it was important to treat pain promptly to prevent worsening pain and causing distress to residents. She stated that DON was responsible for following up and overseeing that orders were correctly entered and follow-up with additional training for nursing staff as needed. She stated that she had been in-serviced on change of condition and notified the provider immediately if change of condition included worsening and not managed pain. During an interview with NP K on 06/02/2026 at 12:36 p.m., she stated that she received the call this morning from RN C regarding Resident #128's pain medications. She was informed that the hospital sent the narcotic triplicate to a different local pharmacy. She stated that the facility has an emergency kit and the hydromorphone (Dilaudid) was not available in the facility's emergency kit. She stated that the facility has a policy to contact on-call providers if there were any medical concerns or changes of condition and no call regarding Resident #128 was received last night. She stated nurses should try to work around this issue (not available medication); ask family to provide medication if available at home while waiting for medication from the pharmacy. She stated that hospitals usually send a controlled drug triplicate to the facility's pharmacy and it was extremely rare to be sent outside of facility's pharmacy. She stated nurses should have called the on-call physician. If this resident did not receive pain meds, it could cause the increased discomfort from cancer and pain level increase. She stated that the consequences of not getting pain medications depended on each resident's situation. During an interview with CNA H on 06/03/2026 at 11:56 a.m., she stated that she worked with Resident #128 starting from 06/02/2026 6 a.m. for two-day shifts (6am-2pm). She stated that when she repositioned Resident #128, she was grimacing and complained of pain during changing positions and during incontinent care and she reported it to RN C. During an interview with CNA E on 06/03/2026 at 10:06 p.m., she stated that she took care of Resident #128 on 2-10 p.m. shifts, and she noticed this resident needed assistance with repositioning and incontinent care. Resident #128's Family member stayed in the room with her. She stated that Resident #128 has a wound in lower back, and she complained of pain when being repositioned, but not a lot and only when moving. She stated that Resident #128 could assist with repositioning holding to the bed rail. She stated that she worked during the shift when Resident #128 was just admitted to the facility and assisted RN B with taking blood pressure and changing this resident. She stated that she did not remember if Resident #128 complained of pain at that time. She stated that she did not remember Resident #128 being in pain a lot, just when moving. Attempted to call the night shift CNA N who worked with Resident #128 on the night of admission, 06/01/2026 - 06/02/2026 and the call was not returned. Attempted to call the oncology providers for Resident #128 and left a message with desk to request a call back which was not returned. During an interview with DON on 06/04/2026 at 1:14 p.m., he stated that he was DON at this facility for 4 years. He stated that medication orders for new admissions were received a few hours before residents were admitted to the facility and ADON entered orders on the system. Resident #128's medications were sent to the wrong pharmacy and that was the reason facility's pharmacy did not receive those orders and did not send those medications to the facility on the night of Resident #128's admission. He stated that admitting charge nurses were responsible for calling on call providers to request additional medications needed for residents if medications were not available at the facility. He stated that Resident #128 had her fentanyl patch applied at the hospital on the day of discharge, so she did have some pain medication that day. He stated that he became aware of this resident complaining of pain and not receiving her pain management on the morning of 06/02/2026. He stated that RN A who worked on 06/02/2026 10 p.m.-6 p.m. was responsible for contacting the pharmacy to verify that ordered medications were coming and contacting on call provider to get a new order for Resident #128's pain management. He stated that RN A could ask the family to bring their own medication from home and utilize that until they were able to get the medication from the pharmacy. DON stated he was notified that night about this issue with medications, even though he called the facility regarding the different questions and spoke to RN A, and she did not tell him that she had an issue with Resident #128's medications. He stated that RN A was a PRN nurse and worked at this facility for a very short time and would not be working here again. He stated that not providing pain medications to Resident #128 could cause an increase in distress levels and other complications. During interview on 06/03/2026 at 2:34 p.m. with ADM, he stated that he was trained on the admission policy regarding all newly admitted residents' medication orders should be entered in PCC. He stated that charge nurses were responsible for entering new medication orders in the residents' charts. He stated that nurses knew that Resident #128 was coming to the facility and orders were sent from the hospital. He stated that Resident #128's orders should have been entered into the system before her admission. ADON and DON were responsible for reviewing medication orders and putting new orders in each resident's order profile in PCC according to physician orders. He stated that when residents were admitted to the facility, the admitting providers see them withing 24hrs, but an on call provider was available to verify orders and adjust orders as needed. ADM stated that admitting nurses were responsible for assessing and reassessing residents, including pain assessment. He stated that residents should be assessed throughout the shift multiple times and assessments including pain assessment should be documented in PCC (medical records). He stated that when residents come and medications were not delivered to the facility, and if residents or residents' RPs were reporting pain, charge nurses were responsible for contacting on call providers requesting pain medication. He stated that the facility's expectation was obtaining new orders to relieve Resident #128's pain as soon as possible. ADM stated that charge nurses were responsible for monitoring that medications arrived from the pharmacy and were available for residents. If pain was not relieved timely and pain would not subside, it could lead to a lot of side effects. During an interview with MD J on 06/05/2026 at 1:56 p.m., she stated that she saw Resident #128 yesterday, 06/04/2026, and she was doing well. She stated that there were physicians and NPs on call for nurses at the facility to contact when they need to get medications due to change of condition. MD J stated that on call providers could assist with ordering medications to be delivered to the facility or order a different pain medication that was available from emergency medication kit at the facility. She stated that it could be tricky if the hospital sent medications to the wrong pharmacy and it could delay getting those medications transferred to the facility's pharmacy, getting new medication orders or getting new narcotic triplicates, but it could be done. She stated that it was an unfortune incident that this resident had to wait for pain medications that long. She stated that nurses at the facility could and should contact a physician or NPs on call to get new orders if the resident complained of pain and did not have any ordered pain medication available at the facility. She stated that she was on call at nights last weekend and it was a common practice to get new orders for new admitted residents at 10-11 p.m. or any other time they needed. She stated that residents with cancer diagnosis including pancreatic cancer were known to experience a fair amount of pain and that was the reason Resident #128 was ordered strong pain medications and required pain management. She stated that not having pain medication available to Resident #128 while she was experiencing pain could cause distress and discomfort. Record review of Pain Management Policy, dated 12/01/2025, revealed Pain management and treatment: based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 10 residents (Resident #13, Resident #48, and Resident #86) reviewed for ADL care. The facility failed to ensure, Resident #48, and Resident #86 did not have unwanted facial hair.The facility failed to ensure Resident #13 was changed or toileted every two hours. This failure could place residents at risk of embarrassment and diminished quality of life.Findings included: 1. Record review of Resident #13's face sheet, dated 06/03/2026, reflected an [AGE] year-old female admitted on [DATE]. Resident #13 had diagnoses which included: traumatic subdural hemorrhage without loss of consciousness (blood collects between the brain and the skull's outermost protective covering following a head injury), history of falling and syncope (fainting or passing out.) chronic diastolic (congestive) heart failure (an individual with a long-standing, stable history of stiff, poorly relaxing heart muscles [chronic diastolic heart failure] has experienced a sudden, severe worsening of their symptoms [an acute decompensation], typically resulting in dangerous fluid buildup), need for assistance for personal care, urinary tract infection, and hypertensive (high blood pressure) heart disease with heart failure. Record review of Resident #13's admission MDS assessment, dated 05/09/2026, reflected Resident #13's BIMS score of 15 which indicated intact cognition response. The MDS also stated Resident #13 was occasionally incontinent for urine and frequently incontinent for bowels. Resident #13 was Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort). Resident #13's MDS revealed (Resident #13 had no current skin issues Record review of Resident #13's care plan, dated 05/10/2026, reflected the following: Focus: ADL self-care performance deficit related to mobility.Goal: [Resident #13] will improve current level of function through the review date.Interventions: The resident requires 1 staff for toileting. The resident requires assistance from 1 or 2 staff to move between surfaces. This may fluctuate with weakness, fatigue, or weight bearing status.Observation of Resident #13 on 06/02/2026 at 1:43 p.m., revealed she was lying in her bed. Her nails were long and had what appeared to be dirt underneath them.During an interview with Resident #13 on 06/03/2026 at 10:19 a.m., she stated that she has to wait to be changed for 2 hours in a wet bed sometimes through different shifts. She stated that she takes diuretics for her heart condition and it makes her urinate more often. She stated that even her pajamas get wet sometimes as nobody comes to check on her and assist her with going to the bathroom. She stated that not being assisted with going to the bathroom timely bothers her due to feeling uncomfortable in wet clothes. She stated that sometimes she could not wait for help any longer and just got up by herself, but she knows she should not get up on her own due to falling at home before and hurting herself. During an observation of Resident #13 on 06/04/2026 at 11:29 a.m., she was sitting in the wheelchair and combing her hair, while CNA H was removing sheets from Resident #13's bed. The sheets on the bed were observed wet with stains of urine. During an interview with Resident #13 on 06/04/2026 at 11:31 a.m., she stated that she was waiting again for somebody to come and change her and her bed was soaking wet due to her urinating on herself and not receiving timely assistance. She stated that the last time she was changed was around 5:00 a.m. Resident #13 stated that CNA H delivered a breakfast tray to her around 8:00 a.m. and she did not see anybody after that until around 11:00 a.m. when therapy came and assisted her with getting up. She stated that she pushed the call light three times and nobody assisted her to go to the bathroom until around 11:00-11:30 a.m. Resident #13 stated: That is what I told you yesterday. I ask for help and have to wait for a while before getting help. During an interview on 06/04/2026 at 11:45 a.m. with CNA H, she stated that she had been trained on answering call lights as soon as possible and checking on residents every two hours. She stated that she brought Resident #13 a breakfast tray around 8 a.m. this morning and did not have time to check on her until now. She stated that she felt bad not checking on Resident #13 all morning due to being extremely busy with other residents on the 700-hall. She stated that this resident was wet and she was changing her sheets due to being wet with urine. She stated that she did not see a call light for this resident and did not know who answered the call light. She stated that she felt that sometimes it could be overwhelming with amount of work on the 700 hall and not being assisted by other team members. During an interview on 06/04/2026 at 11:56 a.m. with RN C, she stated that she was a charge nurse on 700 hall and was taking care of Resident #13. She stated that per facility policy, charge nurses and CNAs were responsible for answering call lights as soon as possible and assisting residents with what they need. She stated that she was busy with other residents all morning and did not see a call light for Resident #13. She stated that she was not aware of Resident #13 was wet and waiting for assistance for a while. She stated that not providing residents with toileting and changing wet clothes could cause the skin breakdown, infection, and concerns' with their dignity. She stated that she felt that she was able to take care of 25 residents on her case load, but it could be hard if some residents required more care and took more time to provide treatments while admitting a new resident. She stated that it was everybody's responsibility to answer call lights and she had training on call lights to be answered as soon as possible. During an interview with the DON on 06/04/2026 at 2:22p.m., he said he had been trained on ADL care. He said the policy was to change the residents every two hours or more if needed. He said the CNAs and nurses were responsible for ensuring the residents were changed. He said if a resident was not changed regularly the resident could have discomfort, skin breakdown and depending on the resident, dignity could be compromised. He said management monitored to ensure staff were changing the residents. He said management monitored by doing rounds on the residents. He said he did not know why Resident #13 was soaked in her brief. He said the aide told him she did not notice her call light was on. During an interview with the ADM on 06/04/2026 at 2:53p.m., he said he had been trained on ADL care. He said the policy for changing the residents was that staff were to change the residents every two hours or as soon as possible. He said the CNAs were responsible for changing the residents. He said if a resident was not changed regularly the resident could have skin breakdown, infections, and dignity issues. He also added that a resident should not be left wet. He said the nurses monitored to ensure the CNAs were changing the residents. He said the nurse monitored by doing skin assessments on the residents. He said he did not know why Resident #13 was not changed. 2. Record review of Resident #48's face sheet dated 06/04/2026 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included history of falling, heart failure, muscle weakness, chronic kidney disease stage 3 (a serious condition where the kidneys are severely damaged), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke), hyperlipidemia (high cholesterol), and hypertension (high blood pressure).Record review of Resident #48's admission MDS assessment, dated 04/22/2026, reflected a BIMS score of 0, which indicated severe cognitive impairment. [Resident #48] was [required] Supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity).Record review of Resident #48's care plan, dated 04/16/2026, reflected the following: Focus Self-Care - Personal hygiene: Resident requires supervision or touching assistance.Goals: The resident will complete personal hygiene (brush teeth, comb hair) with Set assistance from staffInterventions: Encourage resident to use call light for assistance. Encourage/give good oral hygiene to prevent staining of the teeth, dentures. Praise all efforts at self-care. Set-up items for personal hygiene. Allow resident to complete as much of the task as possible. Assist as needed.During an observation of Resident #48 on 06/02/2026 at 10:44a.m., revealed she was lying in her bed. She had facial hair on her chin.During an interview with Resident #86 on 06/02/2026 at 10:46a.m., she said that she had been at the facility for two months. She said she had not noticed the hair on her chin. She said no one had offered to shave her hair on her chin. She said she did not feel good about having the hair on her chin.3. Record review of Resident #86's face sheet dated 06/04/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #86 had diagnoses which included dementia (memory, thinking, difficulty), chronic obstructive pulmonary disease (chronic progressive lung disease), chronic kidney disease stage 4 (a serious condition where the kidneys are severely damaged), heart disease, history of falls, pain, and major depressive disorder (mental health disorder characterized by persistent depressed mood).Record review of Resident #86's admission MDS assessment, dated 05/06/2026, reflected a BIMS score of 0 which indicated severe cognitive impairment. The MDS revealed Resident #86 was Dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity required supervision or touching assistance from staff for personal hygiene, which indicated the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) on staff for personal hygiene.Record review of Resident #86's care plan, dated 05/18/2026, reflected the following: Focus: Self Care- Personal hygiene: Resident requires supervision or touching assistance.Goals: The resident will complete personal hygiene (brush teeth, comb hair) with Set assistance from staff.Interventions: Encourage resident to use call light for assistance, Encourage/give good oral hygiene to prevent staining of the teeth, dentures. Praise all efforts at self-care. Set-up items for personal hygiene. Allow resident to complete as much of the task as possible. Assist as needed.During an observation of Resident #86 on 06/03/2026 at 8:42a.m., she was sitting in her recliner eating her breakfast. She had facial hair on her chin.During an interview with Resident #86 on 06/03/2026 at 8:43a.m., she said she had tried to cut her whiskers, but she could not get them. She said staff have not tried to help her shave. She said she would feel better with the whiskers shaved off.Durning an interview with LVN N on 06/04/2026 at 10:03a.m., she said she had been trained on ADLs. She said the policy for facial hair was if the resident does not refuse the CNA should shave the resident to remove the facial hair. She said the CNA was responsible for shaving the residents on their shower day. She said if a resident had unwanted facial hair the resident may feel embarrassed and may not want to talk to people. She said the nurses monitored to ensure the CNAs were shaving residents who wanted to be shaven. She said the nurse monitored by signing off on the shower sheets after the aide had completed a shower. She said the nurse will also go and check to ensure the resident was shaven. She said she did not know why Resident #86 and Resident #48 were not shaven when they did not want the facial hair. During an interview with CNA O on 06/04/2026 at 11:04a.m., she said she had been trained on ADLs. She said the policy for facial hair was to shave the resident on their shower days. She said sometimes the staff shave the residents and sometimes the family does it. She also said sometimes the resident would shave themselves if they were cognitive enough. She said the CNAs and the nurses were responsible for ensuring the residents did not have unwanted facial hair. She said if the resident did not want facial hair the resident may feel embarrassed. She said the CNA's monitored to ensure the residents were shaven. She also said if the resident did not want the CNA to cut the facial hair the CNA would let the nurse know. She said she did not know why Resident #86 and Resident #48 were not shaven when they did not want the facial hair. During an interview with CNA P on 06/04/2026 at 11:22a.m., she said she had been trained on ADLS. She said the policy was that the resident was to be shaved on their shower days. She said if the resident refused the CNA could not do anything about it. She said the CNAs were responsible for shaving the residents, but they have some that only allow the family to shave them. She said the if the resident had unwanted facial hair the resident may be upset. She said the nurses monitored to ensure the residents were being shaved on their shower days. She said the nurses monitored by observation. She said she had shaved Resident #48 on Tuesday. She said she did not know why Resident #86 was not shaved. During an interview with the DON on 06/04/2026 at 2:18p.m., he said he had been trained on ADLs. He said the policy for facial hair was the resident was to be shaved and some residents would refuse. He said it was up to the resident on when their facial hair was there and if they wanted it shaved. He said the CNAs were responsible for shaving the residents. He said the resident may feel uncomfortable or unattractive if they had unwanted facial hair. He said everyone monitored to ensure the residents got shaved. He said everyone monitored by rounding on the residents. He said he did not know why Resident #48 and Resident #86 had not been shaved. During an interview with the ADM on 06/04/2026 at 2:49p.m., he said he had been trained on ADLs. He said the policy for facial hair was that staff were to follow resident rights and ask the resident if they want to shave. He said the CNAs were responsible for shaving the residents. He said if the resident had unwanted facial hair the resident may have a dignity issue and their preference was not being honored and enforced. He said the nurses monitored to ensure the residents were getting shaved. He said then the managers would check with the residents daily and ask the resident if everything is up to their standards. He said management would also make observations. He said he did not know why Resident #86 was not shaved. He said Resident #48 would change her mind from time to time. Record review of the Promoting/Maintaining Dignity Policy dated 10/01/2025 revealed It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, which maintains or enhances resident's quality of life by recognizing each resident's individuality. Groom and dress residents according to resident preference.

Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 7 residents (Resident #28, Resident #13, and Resident #127) reviewed for quality of care. The facility failed to ensure: Nursing staff weighed Resident #13 and Resident #127 every day according to their care plan and physician's orders due to their CHF diagnosis. Nursing staff provided wound care for Resident #28 according to her care plan and physician's orders. These failures could place the residents at risk of fluid overload, infection, and hospitalization.Findings included. 1.Record review of Resident #13's face sheet, dated 06/03/2026, reflected [AGE] year-old female admitted on [DATE] with diagnoses that included: traumatic subdural hemorrhage without loss of consciousness (blood collects between the brain and the skull's outermost protective covering following a head injury), history of falling and syncope (fainting or passing out), acute on chronic diastolic (congestive) heart failure (an individual with a long-standing, stable history of stiff, poorly relaxing heart muscles [chronic diastolic heart failure] has experienced a sudden, severe worsening of their symptoms [an acute decompensation], typically resulting in dangerous fluid buildup), need for assistance for personal care, urinary tract infection, and hypertensive (high blood pressure) heart disease with heart failure. Record review of Resident #13's admission MDS assessment, dated 05/09/2026, reflected Resident #13's BIMS score of 15 - intact cognition and active diagnoses indicated heart failure (congestive heart failure). Record review of Resident #13's comprehensive care plan, dated 05/10/2026, reflected a focus: Resident has altered cardiovascular status related to Atrial Fibrillation (a heart arrhythmia), CHF, hypertension, hyperlipidemia, Aortic stenosis (type of heart valve disease that prevents the aortic valve from opening fully) with interventions Assess and monitor cardiovascular status/identify complications. Monitor for signs and symptoms that the cardiovascular condition could be worsening or not controlled., and focus: risk for falls with interventions: Anticipate and meet the resident's needs., focus Resident is on diuretic therapy (the use of prescription medications, commonly called water pills to help the kidneys eliminate excess salt and water from the body through urine leading to frequent urination). Record review of weights and vitals summary for Resident #13, dated 06/03/2026, revealed the weight was measured on 05/07/26, 05/12/26, 05/16/26, 05/18/26, 05/19/26. 05/20/26, 05/21/26, 05/22/26, 05/23/26, 06/24/26, 05/25/26, 05/30/26, 05/31/26 and 06/01/2026 which indicated inconsistency with the order to weight Resident #13 daily. Record review of order summary report dated 06/03/2026, revealed an order with start date of 05/06/2026: Weight every day shift related to acute on chronic diastolic (congestive) heart failure. Notify provider f weight gain/loss >3 pounds. Observation of Resident #13 on 06/04/2026 at 11:29 a.m. did not reveal any signs and symptoms of fluid overload (occurs when the body retains too much water and sodium, placing excess strain on the heart, lungs, and kidneys. Common signs include rapid, unexplained weight gain, noticeable swelling in the limbs and face, and shortness of breath). During an interview on 06/04/2026 at 11:29 a.m. with Resident #13, she stated that she never refused to be weighed as she understood the importance of monitoring her weight for her heart condition. She stated that she takes a water pill for getting rid of extra fluid in her body, that's why she pees a lot and needs to be changed more often. Record review of Resident #127's face sheet, dated 06/03/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: fracture of lower end of left femur, fracture around internal prosthetic left knee joint, and acute on chronic diastolic (congestive) heart failure. Record review of Resident #127's admission MDS assessment, dated 05/30/2026, reflected Resident #127's BIMS score of 15 - intact cognition and active diagnoses indicated heart failure (congestive heart failure). Weight was identified as 115 pounds. Record review of Resident #127's comprehensive care plan, dated 05/28/2026, reflected a focus: Resident #127 has an implanted cardiac pacemaker with interventions of monitoring vital signs. Notify MD of significant abnormalities. Record review of order summary report for Resident #127 revealed an order with start date of 05/29/2026: Weight every day shift related to acute on chronic diastolic (congestive) heart failure. Notify MD/NP of weight gain/loss > 3 pounds. Record review of weights and vitals summary for Resident #127, dated 06/03/2026, revealed the weight record for only for one day recorded: 6/2/2026 - 107.2 pounds which was 7.8 pounds less than at admission. No other weights were documented for Resident #127. Record review of Resident #127's progress notes did not identify any nursing notes regarding unobtained weights and reasons why they were not obtained. During an interview on 06/04/2026 at 9:43 a.m. with Resident #127, she stated that she never refused to be weighed as she understands why her doctor ordered it to monitor her fluids going in and out. She stated that not all CNAs and nurses have time to weigh her and she was not weighed regularly. During an observation Resident #127 on 06/04/2026 at 9:53 a.m., she was sitting in a recliner with elevated legs. The signs and symptoms of fluid overload (rapid weight gain, noticeable swelling [edema]in the extremities or abdomen, and shortness of breath) were not observed at that time. During an interview with UM M on 06/04/2025 at 11:15 a.m., she stated that she was responsible for overseeing that residents' weighing was completed and documented according to physician's orders and their care plans. She stated that CNAs and charge nurses were responsible for weighing residents on their hallways. She stated that the DON was monitoring and going over completion of weights during morning meetings especially for residents with congestive heart failure as those residents had been closely monitored for fluid retention. She stated that tracking these small changes could allow for noticing the change of condition sooner. She stated that Resident #13 and Resident #127 had orders to be weighed every day and not following those orders could affect their health and lead to hospitalization. During an interview on 06/04/2026 at 11:46 a.m. with CNA H, she stated that CNAs were supposed to weigh certain residents according to the list they received from the charge nurses and sometimes they did not have time or residents were busy at therapy, so they could not always weigh them according to the order. She stated that she weighed Resident #13 and Resident #127 several times and could not remember when she did not do that. She stated that she understood the importance of weighing these residents due to their heart condition. She stated that these residents never refused to be weighed. She stated that she was supposed to notify thecharge nurses about weight results and nurses documented results in the electronic charts and if she did not weigh those residents, she was supposed to let nurses know, so next shift would weigh them. During an interview on 06/04/2026 at 12:06 p.m. with RN C, she stated that charge nurses were responsible for monitoring residents' weights and specifically residents with CHF (congestive heart failure) diagnosis. She stated that she provided her CNAs with a list of residents at the beginning each shift and expected them to complete that task. She stated that some CNAs were better and some were not as responsive to her instructions. She stated that sometimes CNAs were too busy and residents were not available, but still she was responsible for following up and documenting weights in residents' charts. She stated that residents with CHF diagnosis like Resident #13 and Resident #127 were on an everyday weight order and should be weighed every day due to the need to monitor their weights closely to prevent fluid overload which could cause change of condition and hospitalization. She stated that nurses were responsible for notifying the provider if weights were out of normal range or not completed. She stated that these residents were not weighed on several occasions and she was not sure why, but it was not documented and physician was not notified according to the nursing notes. She stated that not weighing those residents according to the physician's orders could be potentially harmful to residents. During an interview with ADON on 06/04/2026 at 12:34 p.m., she stated UM M was responsible for monitoring residents' weights per physician orders. She stated that CNAs were responsible for following charge nurses' orders to take weights for specific residents and with different frequency as some residents that have diagnoses of CHF (congestive heart failure) were required to be weighed every day to prevent the fluid overload. ADON stated that they discuss weights at morning clinical meetings and the DON monitors the following of orders to weigh residents and reminds nurses if weights were not taken or not documented in residents' charts. She stated if they did not follow ordered weights, these residents could experience change of condition and hospitalization. She stated that wound care should be provided on a regular basis without missing treatments and document/notify nursing management, providers, and residents' RPs if wound care treatment was missed. She stated that if wound care was missed, it could cause worsening of condition and delay in wound healing. 2.Record review of Resident #28's face sheet, dated 06/03/2026, reflected a [AGE] year-old female, admitted on [DATE] with diagnoses of multiple fracture of ribs, left side, history of falling, and pain. Record review of Resident #28's admission MDS, dated [DATE], revealed BIMS 15 - intact cognition with indication of prior surgery involving fusion of spinal bones and surgical wound/wound care treatment. Record review of Resident #28's base line care plan, dated 05/28/2026, reflected a focus: Risk for impaired skin integrity related to pressure from TLSO Brace (a rigid or semi-rigid medical-grade spinal brace.): with intervention in place: Remove per schedule for skin checks and hygiene unless MD ordered not to remove and report redness, blisters, or breakdown immediately. Record review of order summary report for Resident #28, dated 06/04/2026, revealed an order for wound treatment: Xeroform every day shift related to wedge compression fracture. Cleanse wound to upper back with normal saline. Pat dry, apply xeroform to wound. Cover with bordered foam dressing.An observation and interview of Resident #28 on 06/02/2026 at 9:36 a.m. revealed Resident #28 sitting in the recliner without back brace on. She stated that she needed it only when she was walking and it hurt her to keep in on all the time. She stated that she had a wound on her back.Observation and Interview with resident #28 on 06/02/2026 at 9:43 a.m. Resident #28's wound dressing with date of 05/29/2026 signed by TN L revealed the slight redness around the dressing without foul smell or other signs of infection were identified at that time. Resident #28 stated that she worried that her wound was not cleaned every day as it was supposed to be according to the doctor's order. Attempted to observe the wound care on Resident #28 on 06/03/2026 revealed that this resident was sent to the hospital for a routine wound debridement procedure. During an interview with DON on 06/04/2026 at 1:14 p.m., he stated that he was DON at this facility for 4 years. He stated that charge nurses were responsible for making sure that weight orders were followed which could be on the daily, weekly, or monthly basis depending on different diagnosis like residents on dialysis or CHF diagnosis. He stated that it was very important for residents with [NAME] diagnosis to be weighed every day to monitor their fluid retention and prevent fluid overload. He stated that this facility was very busy with a lot of new admissions and acuity of residents, so it was difficult to monitor every single weight was done, but it should be done. He stated that Resident #13 and Resident #127 did not refuse to be weighed and charge nurses and CNAs should document if for some reason they were not able to complete the task which pops up on the computer for nurses to complete and they were supposed to document if it was completed and why it was not completed. He stated that charge nurses were supposed to notify him and providers if weights were not completed for any reason. He stated that the wound care should be completed on a regular basis and he became aware that Resident #28 did not receive her ordered wound care for 3 days including the weekend when a treatment nurse was not in the building and charge nurses were responsible for completing wound care tasks. He stated that he talked to the weekend supervisor emphasizing importance of monitoring that wound care was completed especially since there were not so many residents with everyday orders for wound care. He stated that if wound care was not provided according to physician orders, it could cause wounds to not heal properly and possible worsening of wounds. During an interview on 06/04/2026 at 3:39 p.m. with ADM, he stated that CNAs were responsible for weighing residents as scheduled or ordered by physicians. He stated that the charge nurses were supposed to follow the orders for weighing residents every shift according to the PCC - nursing task, and report daily on the clinical meetings, document in the weight log at each nursing station report to DON who supervised this task was completed and who reported the weight results or concerns on the weekly basis on clinical facility wide meetings. He stated that he was not aware that nurses were supposed to notify the provider if weights were not completed. He stated that if residents with CHF were not weighed according to the physician orders, it could deteriorate their health. Nursing staff could catch change by monitoring weight for these residents and attend to their needs before significant changes happened. He stated that the wound care nurse who worked Monday to Friday was responsible to follow up on the orders of physicians. The ADON, DON and ADM, wound care provider and physicians were responsible for monitoring if any change of condition happened and should be notified by charge nurses if orders were not followed. He stated that if not the wound care orders, follow orders, wounds could deteriorate and lead to increase in pain and discomfort. During interview with MD I on 06/03/2026 at 3:44 p.m., he stated that at his professional opinion a treatment nurse was supposed to follow EBP during all wound care procedures regardless of type of wounds. He stated that visitors or nursing staff that come to administer medication or meals did not have to follow EBP with those residents. He stated that without following EBP with those residents could potentially increase risk of complications. During interview with MD J on 06/05/2026 at 8:33 a.m., she stated that wound care was not her specialty, but she was leaving it to facility's discretion and thought it was specific to type of wound. Record review of facility's policy Wound treatment management, dated 12/1/2025, revealed to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatment in according with current standards of practice and physician orders.Policy explanation and compliance guidelines: 1. Wound treatment will be provided in accordance with physician orders, including . the frequency of dressing change.

Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for all residents who consumed foods orally from the only kitchen in the facility that: The facility failed to provide palatable food that was attractive or appetizing to residents who complained the food did not look or taste good and that it was frequently cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, food borne illnesses, and diminished quality of life.During an interview on 06/02/2026 at 1:05 p.m., it was revealed that Resident #18's only complaint was that her soup was too salty. During an interview on 06/02/2026 at 3:29 p.m., Resident #17 stated his meals were served cold almost every day. The resident stated he ate in his room daily. The resident stated his meals were rarely ever hot or warm enough. During an interview on 06/02/2026 at 3:34 p.m., Resident #118 stated her meals were served cold often. The resident stated she ate in her room daily. The resident stated meal services rarely ever had hot food. The resident stated her food did not taste good because it was not hot enough. In a confidential resident meeting at an undisclosed date and time, 5 of 9 said soup served on 06/02/26 was watered down. Residents said that the [NAME] was watering it down so it will go further. During an observation on 06/03/2026 at 1:09 p.m., it was revealed that staff were serving meal trays to hallway 300 residents. Resident # 41's pot roast's temperature was at 122 degrees, Resident # 63's carrots were at 128 degrees, and the roasted red potatoes were at 112 degrees. During an observation on 06/03/2026 at 1:18 PM, a test tray was provided by NSD. The test tray contained a bowl of chicken and vegetable soup. The soup was tasted by 3 surveyors, and it was the consensus of the 3 surveyors that the soup was excessively salty. During an observation on 06/04/2026 at 1:37 p.m., a test tray included a puree diet plate that included chicken parmesan, fettuccine, Italian vegetables, garlic bread, and fresh baked cookie. The chicken parmesan puree was only slightly warm, and the fettuccine puree was runny, and it was visually unappealing. During an interview on 06/02/2026 at 9:02 a.m., NSD stated the residents' hot food should be served at 135 degrees or above and the cold food should be served no higher than 37 degrees. NSD stated that the kitchen staff is responsible for maintaining the correct temperature of cooked and prepared food until the food leaves the kitchen. NSD stated the kitchen staff place the prepared food trays on a cart, and the cart is then brought to the appropriate hallways to be delivered to the residents' rooms by the nursing staff. NSD stated it is his expectation that the food temperatures will be maintained until the food is placed in front of the residents. NSD stated residents could get sick from foodborne illness if food is not kept at appropriate temperatures. NSD stated the residents have the right to make special requests for food. NSD stated he attends the Resident Council meetings often so he can get feedback regarding the food from the residents. NSD stated it is the RD's responsibility to report changes in the residents' preferences or dietary requirements. During an interview on 06/02/2026 at 12:25 p.m., it was revealed that DA Q has been trained in food safety. DA Q said the kitchen staff are responsible for cooking the food and maintaining the temperature until the residents have received the food. She said if food temperatures are not maintained a resident could get sick. She said she is responsible for taking the meal plate from the steam table, placing it on the food tray, covering the food plate, and then putting the food tray in the hall cart. During an interview on 06/04/2026 at 10:05 a.m., LVN N revealed staff have been trained in cooked food temperatures. LVN N stated the kitchen staff are responsible for monitoring the palatability and the temperatures of the food. She said the nursing staff are responsible for delivering food to the residents right after it comes out of the kitchen. She said the kitchen should make the food palatable, but the nursing staff can provide residents with additional spices to accommodate their preferences of taste. She said residents have a right to receive food that is served at the proper temperature and that it tastes good. She said the residents could get upset if they do not get their food the way they like it. LVN N said, I would not want to eat it if it didn't taste good or it was not hot enough. She said a resident could be at risk of losing weight if they did not have a palatable diet. During an interview on 06/03/2026 at 9:39 a.m., it was revealed that Regional Culinary Operations Manager has worked for this company for over 10 years and she visits the facility 1 to 2 times per months. She stated her role is in Operations and she is responsible for temperatures of food, and temperatures of dishwasher and refrigeration units. Regional Culinary Operations Manager stated it is her expectation that the food should be served to the residents when it is hot. She said the facility could get more staff on the food line to speed the food tray delivery to the residents. She said the facility has recently purchased another food cart so the food can be delivered quicker. She said the residents should receive palatable food when the nursing staff serve them in the dining room or in their rooms. She said the residents may feel bad if they do not get good tasting food. Record Review of the facility's policy titled, Food: Quality and Palatability dated 5/2014 and last revised on 06/2026 revealed the following: Policy Statement:Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. DefinitionsProper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures2. The Cook(s) prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.The facility failed to ensure dietary staff followed proper handwashing and glove use.These deficient practices could place residents at risk for food borne illness.Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services.The facility failed to ensure dietary staff followed proper handwashing and glove use.These deficient practices could place residents at risk for food borne illness.The findings were:During an interview on 06/02/2026 at 9:11 a.m., it was revealed that DA Q has been employed at this facility since March of 2026, she has a current Food Handlers Certificate, and she has been trained in Food Service Safety and Sanitation. She stated she has been in-serviced on hand washing and glove use in the kitchen. She said, I must wear gloves for all tasks in the kitchen involving food, then I am to remove gloves between tasks, wash my hands and put on new gloves. I am never to reuse gloves. If we do not use proper hand sanitation, it could cause cross contamination, and a resident could get sick.During an observation and interview on 06/02/2026 at 12:25 p.m., it was revealed DA Q reached over the steam table, obtained a meal plate with bare hands touching the plates food surface. DA Q stated, she was not sure if she was to wear gloves while working on this food service task.During an interview on 06/02/2026 at 10:55 a.m., it was revealed that DA R has worked at this facility for approximately 4 months and she has a Food Handlers Certificate. She stated that she has been trained in hand sanitation and kitchen sanitation. She said, sanitation is to prevent transfer of germs. She said, Someone could get sick if I do not wash my hands for 20-30 seconds. She stated, I must always wear gloves, and I must change gloves between projects or when they get dirty. During an observation in the kitchen on 06/02/2026 at 10:55 a.m., it was revealed that DA R took off one glove from her right hand and she placed it on the steam table. It was observed she used her bare right hand to pick up her mobile phone. DA R held the mobile phone with her left/gloved hand, and she began texting with her right hand. DA R used her right / ungloved hand to place the mobile phone on the steam table between the cloth napkins and the sanitized silverware. DA R said she was texting regarding her schedule for work. Observation included, DA R picked up the right/dirty glove, and she put it back on her right hand. DA R then removed the right/dirty glove and she threw it away. DA R did not wash hands, she then obtained one new glove, and she put it on her right hand, and she continued the task of placing silverware in the napkins.During an observation on 06/02/2026 at 12:10 p.m., it was revealed the DA R walked from the steam table to a kitchen tray storage cart. DA R did not wash her hands or use gloves as she lifted her clothed elbow, and she placed it on the stack of clean lunch trays.During an Interview on 06/02/2026 at 11:05 a.m., it was revealed by NSD that no staff are supposed to have a cell phone in the kitchen. He said, the mobile device is not sanitary. NSD stated it was his expectation that all staff follow proper hand sanitation. He stated that a resident could become ill if they do not follow hand sanitation policy. NSD stated we need to re-educate the staff on hand sanitation.During an interview on 06/02/2026 at 11:07 a.m., it was revealed that RD has worked as a consultant for this facility for 2 years. She said she visits the facility 1 time per week and she regularly observes staff sanitation practices. RD stated, it is my expectation that staff wear gloves when handling food. She said they are to take gloves off if they leave the line, if they touch clothing, or touch their face. She stated, it is unsanitary to bring a cell phone into the kitchen for any reason. RD stated the NSD usually conducts the in-services for the kitchen staff, but I will do an in-service if I am called upon to do so.During an interview on 06/03/2026 at 9:39 a.m., Regional Culinary Operations Manager stated she has worked for this company for around 10 years, and she visits the facility 1-2 times per month. She stated her role is Operations, Regulation and temperature and Sanitation. She stated it is her expectation that all staff follow the policies regarding handwashing and kitchen sanitation. She said staff are to wear gloves when handling food. She said staffs' hands or bodies should not meet clean trays and clean serving surfaces. She said staff are to wear gloves when they are moving a dish with food on it from the serving area to a tray. She says staff have all been training on kitchen sanitation including handwashing, glove wearing and glove changing. Food Service Certifications were reviewed for 12 of 12 kitchen staff, and each certificate is current.Record review confirmed that staff was in-serviced on 06/03/2026 on the following topics: proper hand-washing techniques, glove usage and cleanliness of staff uniforms, hair net usage and not bringing foreign objects into the kitchen.Record Review of the facility's document dated March 2003, revised 06/2026, General Sanitation of Kitchen revealed: Policy: The Nutrition Services Staff shall maintain the sanitation of the kitchen through compliance with a written cleaning schedule.Procedure:6. Staff will wear rubber gloves and an apron to protect clothing while .Record Review of the facility's document dated March 2003, revised 06/2026, Hand Washing revealed: Policy Nutrition Staff will wash hands before starting work, when retuning to work, after smoking, eating, drinking, after visiting restrooms, after handling garbage or poisonous compounds, after removing gloves and at other times hands have been soiled. Dishwashers should always wash/sanitize their hands before handling clean dishes. Hand washing facility should be readily accessible and equipped with paper towels and soap.1. Turn on faucet using paper towel.2. Wet hands and forearms with warm water [NAME] antibacterial soap.3. Scrub well with soap and additional water as needed, scrubbing all area thoroughly.4. Rinse thoroughly.5. Dry hands with paper towel, turn off faucets with towel and discard.6. Application of hand lotion is not advised.7. Staff are educated on the importance of hand washing, retraining, and reminding as necessary on the above policy/ procedure.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 5 of 12 residents (Resident #128, Resident #90, Resident #41, Resident #37, and Resident #60) reviewed for infection control. Facility failed to ensure: TN L sanitized the over-the-bed table prior to setting supplies on it for Resident #90's wound care, did not put on PPE (gown) before providing care to Resident #128 and Resident #90 and did not sanitize her hands two times between changing gloves during Resident #90's wound care. MA D sanitized her hands between changing gloves after performing eye drops for Resident #60 and failed to sanitize the blood pressure cuff between Resident #37 and Resident #41. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization. Findings included: 1.Record review of Resident #128's face sheet, dated 06/03/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of malignant neuroendocrine tumors (pancreatic cancer), secondary malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct (a network of tiny, branching tubes located inside the liver), and pain. Record review of Resident #128's base line care plan, dated 06/01/2026, reflected a focus: Enhanced barrier precautions with interventions: implement enhanced barrier precautions and monitor for signs and symptoms of infections. Record review of Resident #128's admission MDS, dated [DATE], no BIMS score was identified, and no information of wound care was identified. Record review of Resident #90's face sheet, dated 06/03/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cellulitis (bacterial infection of the skin and the soft tissues beneath it) of right lower limb, acquired absence of right leg below knee, sepsis (the body's extreme, life-threatening reaction to an infection), anxiety, and type 2 diabetes mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Record review of Resident #90's admission MDS, dated [DATE], reflected a BIMS score of 14 - intact cognition and presence of surgical wound with application of ointments/medications to wound. Record review of Resident #90's care plan, dated 05/07/2026, reflected a focus: Resident #90 has cellulitis of right foot with interventions in place: give antibiotics for infection and mild analgesics to relieve discomfort and no EBP precautions for wound care were reflected in the care plan. During an observation and interview of wound care conducted by TN L on 06/03/2026 at 1:45 p.m., for Resident #128, TN L checked an order and stated that a new order was place for Triad cream every day shift for stage with cleansing wound to sacral/coccyx area with normal saline or skin cleanser. Pat dry. Apply triad cream. Leave open to air. The new order replaced the order: apply triad cream, silver alginate, and cover with mepilex foam dressing with border. Change daily and as needed. She set up the over-the-bed table stating she had already cleaned it. She washed hands and applied gloves. She removed the old dressing with date on it indicating: 06/02/2026. She stated that Resident #128 just got the pain medication. Resident was grimacing when she turned but stated she was ok. TN L cleaned the wound by removing some slough (by product of the body's inflammatory response) and small amount of drainage. No PPE was available in Resident #128's room. TN L removed contaminated gloves, sanitized hands, and reapplied gloves again, she was leaning to Resident #128's bed with her uniform touching Resident #128's sheets. She wiped Resident 128's bowel movement and removed and reapplied gloves with proper sanitizing hands with observation of not sanitizing hands between changing contaminated gloves -one time. TN L washed hands at the sink after completing wound care task and before exiting Resident #128's room. During observation of wound care conducted by TN L on 06/03/2026 at 2:20 p.m. for Resident #90, TN L moved her treatment cart and an over-bedtable with her to Resident #90's room. TN L did not sanitize an over-bedtable before putting wound care supplies on the table. She sanitized her hands before entering the room and put gloves on in the Resident #90's room, she removed old dressing, properly cleaned the surgical incision with small, dehisced (to split or bust open) area of incision. She removed her gloves after changing dressing and put on new gloves without sanitizing hands between gloves change on Resident #90. TN L applied the dressing and dated the dressing. She removed contaminated gloves and sanitized her hands before exiting the room. No EBP precaution protocol was followed during the wound care for Resident #90. During interview with TN L on 06/03/2026 at 2:41 p.m., she stated that she had an infection control training last week with ADON who was an infection preventionist. She stated that per policy it was required to sanitize hands between gloves changes and after completing the procedure or before exiting resident's room. She stated that it was a requirement to sanitize an over bed table that she used for placing wound care supplies between residents. She stated that she forgot to sanitize the table between Resident #128 and #90. She stated that, according to her understanding, EBP precautions should be followed only for certain wounds and for Resident #128 and Resident #90 no orders were placed, and no PPE equipment was provided, and signs were posted outside of residents' rooms if they were on EBP or other type of infection control precautions. She stated that if she did not follow proper infection control and hands hygiene, she could introduce infection to other residents. 2.Record review of Resident #60's face sheet, dated 06/03/2026, reflected a 79-years-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of cataract (when normally clear lens inside the eye becomes cloudy), adjustment disorder with mixed anxiety and depression mood, and hypertensive heart disease (high blood pressure) with heart failure. Record review of Resident #60's comprehensive care plan, dated 02/18/25, revealed Resident #60 had an ADL self-care performance deficit related to impaired balance. Record Review of Resident #60's quarterly MDS, dated [DATE], revealed his BIMS score of 15 - intact cognition. Observation on 06/03/2026 at 8:11 a.m. of MA D revealed she administered clear eye drops to Resident #60 and did not sanitize her hands after removing gloves and leaving Resident #60's room. Record review of Resident #37's face sheet, dated 06/03/2026, revealed [AGE] year-old male admitted on [DATE] and readmitted [DATE] with diagnoses of history of embolism and thrombosis (blood clots in blood vessels), gastroesophageal reflux disease without esophagitis (reflux), insomnia. Record review of Resident #37's annual MDS, dated [DATE], revealed his BIMS score of 13 - intact cognition. Observation of MA D after completing using blood pressure cuff on Resident #39, she did not disinfect the cuff before and after using the same blood pressure cuff on Resident #41. MA D was observed putting the blood pressure cuff on her medication cart without sanitizing it. Record review of Resident #41's face sheet, dated 06/03/2026, reflected an [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of dementia with mood disturbance, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia. Record review of Resident #41's quarterly MDS, dated [DATE], revealed his BIMS score of 15 - intact cognition. During an interview on 06/03/2026 at 8:34 a.m., MA D stated she did not sanitize the blood pressure cuff between residents when she checked their BP because she was not aware she was supposed to do it. She stated that she started to work at this facility for 2 weeks and she had hygiene and infection control in her services on hands on her 1st day. She stated she knew that she was supposed to sanitize or wash her hands between gloves change, but she was not trained on sanitizing the blood pressure cuff between residents during medication pass. She stated that not sanitizing her hands between gloves changes and not sanitizing the blood pressure cuff between residents could transmit infection between residents. During an interview with ADON on 06/04/2026 at 11:08 a.m., she stated that she was working at the facility for 12 years as the Infection Preventionist. She stated that she was responsible for overseeing that nursing staff followed infection control and hand hygiene policies properly and provided additional training to staff as needed. She stated that infection control training is provided on hire, annually and as needed. She stated that all staff should sanitize hands between gloves change, sanitize the table before placing the wound care supplies between residents and sanitize the blood pressure cuff between residents to prevent spread of infection. She stated that according to the facility's policy EBP is followed only for residents with specific wounds like chronic wounds and with infection. During an interview with DON on 06/03/2026 at 1:31 p.m., he stated that ADON and himself were responsible for monitoring that proper infection control and hand hygiene policies were followed by nursing staff. He stated that infection control training was provided to staff on hire, annually, and as needed basis. He stated that nursing staff were supposed to sanitize their hands between gloves change, sanitize the table before placing clean wound care supplies, and sanitize blood pressure cuff between residents to prevent spread of infection to residents. During interview with ADM on 06/04/2026 at 3:39 p.m., he stated that he had an infection control and hand hygiene training at hire about 3 months ago. He stated that all employees received training on infection control and hand hygiene at time of hire from the Infection Preventionist, ADON, who provided the training. He stated that the web training, assessment on paper, quarterly and annual are available to all employees at the facility. He stated that it was usually a joint effort on abuse and neglect provided by him and infection control presented by Infection Preventionist and other departments present on other topics to new employees during new hire orientation. He stated that he would expect staff follow the proper hand hygiene - sanitizing hands between gloves change, sanitizing table before putting wound care supplies between residents, and sanitizing the blood pressure cuff between residents to prevent the spread of bacteria to residents and staff. He stated that the facility's EBP was to follow the physician orders and follow EBP precautions for dialysis residents, residents with invasive devices like catheters, wounds that are actively infected and not for all wounds. Record review of facility's policy Personal Protective Equipment, dated 11/01/2025, revealed: This facility promotes appropriate use of personal protective equipment to prevent of transmission of pathogens to residents, visitors, and other staff. Indication/consideration for PPE use: -Gloves: Perform hands hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene.-Gown: Wear gowns to protect arms exposed to body areas and clothing from contamination with blood, body fluids, and other potentially infection materials. -Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. Record review of facility's policy Infection prevention and control program, dated 10/01/2025, revealed Staff education: All staff should receive training, related to their specific roles. Record review of facility's policy Enhanced Barrier Precautions, dated 12/1/2025, revealed Policy: it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Initiation of Enhance Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC but my be considered epidemiologically important. Record review of CDC Enhanced Barrier Precautions policy, dated June 28, 2024, revealed that Enhanced Barrier Precautions to include all residents with wounds or indwelling medical devices, regardless of MDRO status. Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized. Available evidence suggests that the routine use of EBP for residents with wounds or indwelling medical devices would reduce the transmission of staphylococcus aureus and MDROs. In a randomized clinical trial, routine use of EBP among residents with indwelling medical devices reduced acquisition of MDROs including methicillin-resistant Staphylococcus. aureus, and reduced catheter-associated urinary tract infections.16 In a separate quasi-experimental study, routine use of EBP during high-risk care of residents with wounds or indwelling medical devices was associated with a significant decrease in acquisition and transmission of both methicillin-susceptible and methicillin-resistant Staphylococcus aureus. 19 Interruption of S. aureus and MDRO transmission likely occurs through at least two potential mechanisms: preventing contamination of healthcare personnel clothing by MDRO-colonized residents, and providing protection against MDRO acquisition for non-colonized, susceptible residents. Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO.

Based on interviews and record reviews, the facility failed to ensure the resident had the right to be informed of, his or her treatment which includingrights.ht to be informed in advance, by the physician or other practitioner or professional, of the risk and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #1) reviewed for resident rights .The facility failed to provide information to Resident #1's FM about the change of medication from Lantus (Insulin) to Metformin and its risks and benefits and other alternative options available.This failure could place residents at risk of receiving medications without their prior knowledge or consent.The findings include:Record review of Resident #1's face sheet dated 04/01/26 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses were dementia, dysphasia (swallowing difficulty), type 2 diabetes, pain, hypothyroidism (Low thyroid hormone level), protein-calorie malnutrition, muscle wasting, acute kidney failure, adult failure to thrive, hemiplegia and hemiparesis (paralysis of one side of the body) and muscle weakness.Record review of Resident #1's quarterly MDS dated [DATE] revealed that the BIMS could not be completed as the resident was rarely or never understood. As per the MDS, one of Resident #1's active diagnoses was DM, and the resident required substantial assistance with eating, oral hygiene, and personal hygiene.Record review of Resident #1's Care Plan dated 02/25/26 reflected Resident #1 had DM, and the relevant interventions were providing diabetes medication as ordered by the doctor and monitoring /documenting the side effects and effectiveness.Record review of NP D's order reflected: Lantus Subcutaneous Solution (Insulin Glargine): Inject 8 units subcutaneously at bedtime for DM.-Start Date-12/15/2025 2000 -D/C Date-01/14/2026. Metformin HCL oral tablet 500 mg (metformin HCL): Give 1 tablet by mouth two times a day related to type 2 diabetes mellitus with unspecified complications.-Start Date- 01/25/2026, -D/C Date-01/28/2026 Metformin HCl Oral Tablet 1000 MG (Metformin HCl): Give 1 tablet by mouth every morning and at bedtime for DM.-Start Date- 01/28/2026, -D/C Date-02/03/2026 Insulin Glargine Solution 100 UNIT/ML: Inject 6 units subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications. Hold for BS less than 100.-Start Date-02/03/2026Record review of Resident #1's January and February 2026 MARs reflected that the medications were administered as per the orders. During a phone interview conducted on 01/04/26 at 9:30 a.m., the FM stated that Resident #1 had been on insulin for his diabetes for an extended period, which was effective without any issues. She reported that, sometime in mid-January 2026, NP D discontinued the insulin and initiated Metformin without informing the family or obtaining their consent. The FM indicated that Resident #1 was on Metformin for approximately two weeks and experienced serious side effects. She expressed that if she had been aware of this beforehand, she would not have permitted NP D to make such a change. The FM stated she conducted extensive online research about Metformin and its side effects. She stated that after having Metformin, Resident #1 developed swollen lips and throat, decreased appetite, dysphagia, stomach ulcers, and other complications. The FM also reported informing the ADM in January that she did not want NP D to take care of Resident #1. She stated NP E was involved in Resident #1's treatment team thereafter and she had no concerns with that. She mentioned that she disclosed the Metformin issue to the current ADM, who started working at the facility in March 2026, to ensure measures were taken to prevent similar incidents from occurring in the future.During a phone interview on 01/04/26 at 10:45 a.m., NP D stated she was the NP for Resident #1 in January 26. She stated she changed Resident #1's insulin to metformin for better outcome for his Type 2 Diabetes as Resident #1's BSL was historically very inconsistent. She stated she had taken into consideration of Resident #1's health status and made sure that it was okay to start Metformin. She stated the resident was doing well with Metformin and there were no serious side effects from it. She stated Resident #1 was [AGE] years old with diagnosis of adult failure to thrive. She said he already had issues like dysphagia and lack of appetite before commencing Metformin. She stated Resident #1 had issues related to hypothyroidism and some of these issues could be resolved by increasing the dose. NP D said she could not do this due to the resistance from the family to do so. NP D stated Metformin was relatively a safe medication with very little side effects considering its therapeutic benefits. She stated she never had come across any residents having any serious side effects from metformin, during her seven years of career as NP. NP D stated she had not consulted the family prior to replacing the insulin with Metformin. She stated, she made a mistake by not informing and discussing the therapeutic benefit of the new treatment plan and getting the consent of the family. She stated now she knew that it was resident and their family's right to know about any change in the treatment plan.During a phone interview conducted on 01/04/26 at 11:10 a.m., the MD stated that he was aware of the Metformin incident involving Resident #1 that occurred in January 2026. The MD stated that NP D was supposed to discuss any change in the treatment plan and obtain the family's consent before initiating it. He noted that he would have most likely approved the treatment plan change; however, NP D did not discuss it with him prior to making the change. The MD stated that if she had informed him, he would have advised her to obtain the family's consent beforehand, as this is part of resident rights. He further explained that he had discussed the issue with the family and that the side effects they described were consistent with his assessment of Resident #1's declining health due to other diagnoses, making it unlikely that these symptoms were caused by Metformin.During an interview on 04/01/26 at 12:10 p.m., RN A stated that he attended an in-service on resident rights approximately two weeks ago. He explained that residents had the right to know what medications they were taking, to be informed of any changes to their medications, and to understand the effects and side effects of those medications. He said additionally, residents should be informed of alternative therapies if available.During an interview on 04/01/26 at 12:20 p.m., RN B stated that it is one of the residents' rights to know which medications they were taking, as well as their therapeutic effects and side effects. She added that residents also have the right to refuse any medications if they choose. She mentioned that she attended an in-service on resident rights on 03/20/26.During an interview on 04/01/26 at 12:30 p.m., RN C stated that it was the nurse's responsibility to ensure that residents and their families were informed about any medication changes. He explained that usually the NP placed the order, and if it was a new medication, the nurse in charge verifies whether the NP had communicated the change to the resident and family. If not, it was the nurse in charge to educate the resident and family about the new medication. He stated that residents always have the right to accept or decline medications. He also mentioned that he attended an in-service on resident rights approximately two weeks ago.During an interview on 04/01/26 at 2:00pm, the DON stated that the resident was initially on insulin therapy, which was subsequently changed to Metformin. The family expressed concerns that the resident experienced serious issues, such as a swollen throat and lack of appetite, which they attributed to the use of Metformin. The DON reported that NP D was responsible for changing the resident's medication to Metformin and indicated that she did not communicate the change in medication to the FM. He stated the FM complained about it on 02/11/26 and the issue was resolved immediately after that at FM's satisfaction. The DON further explained that the resident was in his 90s and experiencing a decline in overall health. He noted that the issues raised by the FM as potential side effects of the medication were likely related to the natural aging process, hypothyroidism and health decline in general. The DON mentioned that the resident had a thyroid issue, and the family chose not to pursue treatment for it to avoid additional medications, which may have contributed to the resident's declining physical health as well. The DON stated that the resident was a candidate for hospice care; however, the family was reluctant to pursue this option, as they were struggling to come to terms with his health status. The DON stated that since the change in practitioners, a new practitioner is now in charge of the resident's care, and Resident#1's family had no issues with her.During an interview on 04/01/26 at 2:30pm , the ADM stated that he began working at the facility on March 26. He reported that an incident involving the failure to inform the FM of a change in the treatment plan occurred approximately two months prior, on January 26. He stated the FM's intention was to bring this issue to his attention as the new ADM, to ensure that such an issue would not be repeated. The ADM stated that residents and their families had the right to be informed about treatments, medications, and any changes thereto. He said that NP D did not inform the resident and family about the change, which was identified as inappropriate. Subsequently, he stated that NP D was replaced by NP E on February 26. Since this change, the family has expressed satisfaction with the communication. The ADM stated that the facility had already resolved the issue in February. He added however once he was informed by the family on 03/19/26 about the incident, he had re conducted interventions once again to make sure the issue was resolved effectively and permanently. He said a care plan meeting was held on March 20, 2026, with the FM to discuss the past concerns. The FM reported being satisfied with the outcome and indicated that the issue was resolved.Interviews and record review on 04/01/26 starting from 2:00pm with the ADM, DON and MD, revealed, the facility implemented the following prior to the surveyor's entrance to the facility on [DATE]. The Metformin of Resident #1 was discontinued and reinstated Lantus on 02/03/26.Resident was sent to hospital for further evaluation on 02/11/26The service of NP D was discontinued as requested by the FM.The MD was notified on 02/04/26 and 03/19/26.In person care plan conference conducted with FM on 03/20/26 to discuss past concerns.A psychosocial wellbeing assessment conducted on 03/19/26Self-report to state within 2 hours on 3/19/26Ad Hoc QAPI meeting conducted on 03/20/26In service on resident rights, abuse and neglect and physician order notification changes were conducted for the staff on 03/20/26.The facility maintains ongoing and positive rapport with the family.Record review of the facility's policy revised on 12/01/2025 , titled Resident Rights reflected: Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment.d. The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents (R #1) reviewed for medication administration.The facility failed to administer R#1's physician ordered 4 units of Insulin Lispro Injection solution, prescribed to treat Type 2 Diabetes Mellitus, (elevated blood sugar levels) on 12/19,12/22,12/23,12/24,12/25,12/28,12/29 and 12/30/2025. These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications.Findings include: Record review of R1's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. R1 had diagnoses which included TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (elevated blood sugar levels), HYPOTHYROIDISM (when the thyroid gland doesn't make enough thyroid hormone), BIPOLAR DISORDER (a condition that causes extreme mood swings). ANXIETY DISORDER (Characterized by feelings of fear or apprehension about what's to come and persistent and excessive worry). Resident was discharged to the hospital on [DATE]. Record review of R1's admission MDS assessment, dated 12/25/25, reflected that R1 had a BIMS score of 12 out of 15, which indicated moderate problems with thinking and memory. R1 did not exhibit behavioral symptoms (physical or verbal behavioral symptoms directed towards others). MDS indicated R1 needed some help with everyday functional abilities such as dressing and eating. Record review of R1's care plan reflected a focus of need for insulin as ordered and interventions Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Record review of R1's MAR report indicates R1 received insulin injections on 12 occasions when R1's blood sugar levels were outside the parameters Hold for +BS less than 150 or if patient is not eating. Hypoglycemic protocol for FSBS less the 60. Record review of Physician Orders revision on 12/20/2025: Insulin Lispro Injection Solution( Insulin Lispro) Inject 2 unit subcutaneously three times a day related to Type 2 Diabetes Mellitus without Complication. Order 12/182025. Record review of in-service revealed the following topics were in-serviced on 01/02/2026: Medication Administration and policy review of, abuse and neglect and resident rights.Record review of LVN B's employment file revealed she had a hire date of 03/04/2015 and an official termination date of 01/05/2026. During an interview on 01/09/2026 at 04:05 PM, DON revealed he performed an audit of medication administration on 01/02/2026. The audit revealed that between 12/19/2025 and 12/30/2025 R#1 was administered insulin 12 times outside the prescribed parameters. DON revealed that per R1s MAR, in December of 2025 LVN B administered insulin outside of blood sugar parameters for R1 on December 19th ,22, 23, 24, 25 27, 28, 29 and 30. DON stated, on 12/31/2025 at 6:30 a.m. R1 was reported to have stoke-like symptoms to include lethargy and slurred speech. R1 was transported to the hospital by EMS. DON revealed a record review of R1's blood sugar readings, insulin intake and meal intake were as follows: R1's BS readings on 12/30/2025 at 11:30 a.m. was 117 (outside parameters), 5:00 p.m. reading was 148 (outside parameters). On 12/30/2025 at 11:30 a.m. R1 was administered insulin and 5:00 p.m. resident was not administered insulin. DON stated, on 12/31/2025 R1's scheduled insulin was scheduled to be administered at the upcoming breakfast time at around 8:00 a.m. On 12/30/2025 R1's meal intakes recorded R1 consumed 51-75 % of breakfast and lunch meals, and 76-100 % of dinner meal was consumed by R1. DON stated R1's Diagnosis from hospital is hypoglycemia. (Low blood sugar). Interview on 01/12/2026 AT 12:21 P.M., NP revealed insulin is acting short, and on 12/30/2025 it would have worn off by 5:00 p.m. NP stated, since the resident's food intake was good, the 11:30 a.m. dose would not have affected her BS at 6:00 a.m. the next day. NP stated, R1 was often noncompliant regarding her food intake but, if she had been eating, then I can't say the insulin being given at 11;30 a.m. would have caused her BS to tank at 6:00 a.m. the next day. Policy for Mediation Administration. No date listed on this policy 2 The 6 Rights of Medication Administrationc. Right Dose. Verify the label to MAR, these must match. d. Right Dosage Form. Verify the MAR to label, these must match, Tabs, caps and liquid are not always directly interchangeable.e. Right Time. Confirm med-pass time window (1 hr. before to 1 hr. after administration time on MAR. Also includes giving those meds before or after meals or other meds as instructed on either the mediation label or MAR13 Administration of Intravenous Medication b. Verify provider orders prior to administration.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 residents (R#2), reviewed for pharmaceutical services, in that:The facility failed to ensure Resident #2 had her physician ordered Robaxin (muscle relaxer) 1 500 mg tablet by mouth every 8 hours for pain, available on 01/10/2026.This failure could place residents at risk for not receiving medication as ordered. Findings included: Review of Resident #2 admission record dated 01-08-2026 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes, Chronic kidney disease, Nonalcoholic cirrhosis of the liver (Chronic inflammation of the liver causing gradual scarring), Compression Fracture of the Lumbar Vertebra, (vertebra collapse due to excessive pressure), Malignant breast cancer (producing death or deterioration) and Recurrent Depressive Disorders (multiple episodes of major depression characterized by feelings of sadness, hopelessness and loss of interest in activities). Record Review of Resident #2's MDS, dated [DATE], Section C (Cognitive Patterns) revealed a BIMS score of 12 (moderately impaired cognition). Section G (Functional Limitation in Range of Motion) residents have impairment on both sides of upper extremities. Record Review of Resident #2's Care Plan dated 11/18/2025, revealed, Resident will participate actively in making choices/decisions for care regarding pain management. Record Review of R # 2 's orders dated 01/12/2026 revealed,Tramadol HCI 50 MG was ordered on 01/10/2026 @ 5 p.m.1 tablet by mouth every 6 hours as needed for pain.Fentanyl patch (12 MCG/HR) every 72 hoursMethocarbamol (Robaxin)Oral Tablet 500 MG 1 dose by mouth every 8 hours for painHydrocodone -Acetaminophen 325 MG given for pain 1 tablet by mouth every 6 hours was discontinued on 01/10/2026. Record review of R # 2's MAR dated 01/12/2026 revealed,Tramadol administered PRN on 01/11/2026 at 5:00 PM.Fentanyl patch was ordered on 01/10/2026 and was administered 01/11/2026 at 7:42 AM.Methocarbamol (Robaxin) Order was received on 01/10/2026 at 5:00 p.m and was entered into R2's orders on 11/12/2026. Robaxin was started 01/12/2026 at 12 AM. Missed 1 dose of Robaxin on 01/11/2026 and missed 2 doses on 01/12/2025. During an interview and observation on 01/12/2026, R#2 stated, her daughter told her that she had not received her pain medication on Saturday night. R# 2 stated, she recalled the pain level on Saturday to be 5 out 10. R#2 said she did not ask any of the nursing staff for pain medication on Saturday. R# 2 sated she was not afraid of not getting her medications and she thinks the fentanyl patch is helping reduce the pain. During an interview on 01/12/2026 at 10:25 a.m. Family member reported R#2 was without pain medication from 01/10/2026 at 3:00 p.m. until 01/11/2026 at 4:00 p.m. Family member stated she is making complaints for the purpose of helping R#2 and other residents in the facility. During an interview on 01/12/2026 at 11:18 a.m. DON stated, R#2 was administered the following medications between 01/10/2026- 01/12/2026: Saturday 01/10/1016:- Gabapentin 7 p.m.- [NAME] pass pain patch 8 a.m.- Hydrocodone at 9 am, 3 p.m.- no evening dose because orders were changed around 5 p.m. Saturday.DON stated that LVN A changed orders in the PCC at 5:00 p.m. The new orders were supposed to include scheduled Robaxin 500 mgs every 8 hours in addition to Robaxin PRN. DON stated, LVN A recorded a change of orders to reflect discontinuation of Hydrocodone, but she forgot to put the scheduled Robaxin in the orders.DON stated the following: - Robaxin was ordered and none was given to R#2. He stated, according to the orders, it should be given on the same day as the orders were received.- Tramadol was ordered PRN and none was given to R# 2. - New orders added fentanyl patch every 72 hours and tramadol 50 mg every 6 hours and PRN.- DON stated, the orders did not specificity a time to start the Fentanyl patch however, the Doctor was expecting us to administer tramadol PRN.- New orders discontinued Tylenol, Hydrocodone (scheduled dose and PRN dose) as of 5 p.m. on 01/10/2026.Sunday 01/11/2026: - Robaxin 9:13 a.m. -Tramadol 5 p.m. -Fentanyl 72-hour patch at 7:42 p.m.During an interview on 01/12/2026 at 12:30 p.m., it was revealed that LVN A was responsible for updating orders in R#2's chart. LVN A stated she received orders by text from RN on 01/10/2026 at 4:36 p.m. She stated she updated R#2s chart to include orders to discontinue Hydrocodone (scheduled dose and PRN dose), added fentanyl patch (to be ordered by the physician), Tramadol, PRN and Robaxin was to be changed from PRN to every 8 hours. LVN A stated, I was the charge nurse, and I do take responsibility for not updating the orders immediately.LVN A stated the expectation for starting administration of new medications was to administer them as per orders, immediately.LVN A stated a resident could potentially be in a lot of pain if medications are not given by physician orders. Record review of facility Policy Medication Orders with a revised date of 11/1/2025 revealed: Policy Statement:This facility shall use uniform guidelines for the Ordering of medication.1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe.2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the physician, on the next visit to the facility.4. Documentation of Medication Orders:a. Each medication order should be documented with the date, time and signature of the person receiving the order. The order should be recorded on the physician's order sheet and the Medication Administration Record (MAR).e. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry as per the electronic software instructions and enter the new order.f. Ensure the new order is in the electronic [NAME]. Notify resident's sponsor/ family of new medication orders.

Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, for 5 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of care.The facility failed to ensure Resident #1, Resident #2 , Resident #3, Resident #4, Resident #5's nebulizing masks and/or oxygen canulas were bagged for sanitation when not in use on 11/06/25.This failure could place residents at risk for respiratory infections. The findings included:Record review of Resident #1's face sheet, dated 11/06/25, revealed a [AGE] year-old male, admitted on [DATE]. His diagnoses were multiple fractures of ribs, pulmonary embolism (block by blood clot in lung's artery), Parkinson's disease (kind of neurological disorder), acute respiratory failure with hypoxia (less oxygen), abnormalities of gait and mobility and muscle wasting and atrophy. Resident #1 was sent out to the hospital on [DATE] and returned to the facility on [DATE].Record review of Resident #1's initial MDS assessment, dated 11/03/25, revealed a BIMS score of 10 indicating his cognition was moderately impaired. Record review of Resident #1's care plan, dated 10/23/25, reflected Resident #1 had altered respiratory status/difficulty breathing r/t acute respiratory failure due to PE. The relevant intervention was administering medication/puffers as ordered and monitoring for effectiveness and side effects. Record review of Resident #1's physician's order reflected: Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliters: Inhale orally via nebulizer every 6 hours as needed for wheezing. -Start Date- 11/01/2025. During an observation and interview on 11/06/25 at 10:45 a.m., Resident #1 was in his room. It was observed the mask of his nebulizer was on the side table beside the nebulizing machine. It was exposed to the air and was not in a protective bag. Resident #1 stated he used the nebulizer as needed but not often. Record review of Resident #2's face sheet, dated 11/06/25, revealed an [AGE] year-old female, admitted [DATE]. Her diagnoses were dementia, type 2 diabetes, chronic respiratory failure (Lungs cannot get enough oxugen and remove carbon dioxide) , chronic obstructive pulmonary disease ( breathing difficulty) , muscle weakness, hypertension and chronic cough. Record review of Resident #2's quarterly MDS assessment, dated 09/01/25, revealed a BIMS score of 15 indicating her cognition was intact. Record review of Resident #2's care plan, dated 05/22/25, reflected Resident #2 had emphysema/COPD (lung disease that causes breathing difficulties). The relevant intervention was giving aerosol or bronchodilators as ordered and monitoring /documenting any side effects and effectiveness. Record review of Resident #2's physician's order reflected: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml: Inhale orally via nebulizer every 4 hours as needed for SOB or wheezing related to chronic obstructive pulmonary disease, unspecified. -Start Date- 07/20/2025. During an observation and interview on 11/06/25 at 11:20 a.m., Resident #2 was in her room relaxing in her wheelchair. The nebulizer and its mask were on her bed among the pillows and blanket. Resident #2 stated she was able to self-administer medication via nebulizer; however, staff also helped her with it. She stated no one instructed her to put the mask in a protective bag. An observation at that time revealed there was no protective bag available in her room. She stated she did not get any education on storing the mask. Record review of Resident #3's face sheet, dated 11/06/25, revealed a [AGE] year-old female, admitted [DATE]. Her diagnoses were acute respiratory failure, heart failure, shortness of breath, obstructive sleep apnea, type 2 diabetes, hemiplegia and hemiparesis ( one side paralysis) , muscle weakness, cognitive communication deficit, and anxiety disorder. Record review of Resident #3's initial MDS assessment, dated 05/06/25, revealed a BIMS score of 12 indicating her cognition was moderately impaired. Record review of Resident #3's care plan, dated 06/10/25, reflected Resident #3 had oxygen therapy r/t respiratory failure with hypoxia (low oxygen level in blood), acute on CHF. The relevant intervention was providing oxygen as ordered and medications as ordered by physician and monitoring/ documenting side effects and effectiveness.Record review of Resident #3's physician's order reflected: Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter: Inhale orally via nebulizer every 4 hours as needed for Shortness of breath/wheezing. -Start Date- 07/20/2025. During an observation and interview on 11/06/25 at 1:35 p.m., Resident #3 was in her room lying in her bed awake. She stated she received medication via nebulizer for shortness of breath on an as needed basis. It was observed that her nebulizer with its mask was on the side table. There was no protective bag available for the mask and it was exposed to the air. Record review of Resident #4's face sheet, dated 11/06/25, revealed a [AGE] year-old female, admitted [DATE]. Her diagnoses were acute and chronic respiratory failure, dementia, chronic obstructive pulmonary disease, muscle weakness, cognitive communication deficit, type 2 diabetes mellitus and cough. Record review of Resident #4's initial MDS assessment, dated 07/29/25, revealed a BIMS score of 13 indicating her cognition was intact. Record review of Resident #4's care plan, dated 04/28/25, reflected she had altered respiratory status/difficulty breathing r/t acute respiratory failure, COPD, CHF and, OSA. The relevant intervention was administering medication/puffers as ordered and monitoring for effectiveness and side effects. Record review of Resident #4's physician's order reflected: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial: Inhale orally vianebulizer two times a day for SOB/wheezing for 3 Days -Start Date- 11/06/2025. During an observation and interview on 11/06/25 at 1:10 p.m., Resident #4 was in her room sleeping. Her nebulizer was on the side table and the mask was on the floor. Resident #4 stated she was not sure how long it was on the floor . Record review of Resident #5's face sheet, dated 11/06/25, revealed a [AGE] year-old male, admitted [DATE]. His diagnoses were sepsis due to Escherichia coli, urinary tract infection, acute congestive heart failure, acute kidney failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, muscle wasting, muscle weakness, cognitive communication deficit and, pain. Record review of Resident #5's initial MDS assessment, dated 10/29/25, revealed a BIMS score of 11 indicating his cognition was moderately impaired. Record review of Resident #5's care plan, dated 10/22/25, reflected Resident #5 had oxygen therapy r/t COPD and the relevant intervention was providing oxygen as ordered. Record review of Resident #5's physician's order reflected: Oxygen: Oxygen at 2L/M per NC cannula every shift. -Start Date-10/23/2025. During an observation on 11/06/25 at 11:00 Resident #5 was not in his room. There was an oxygen concentrator, and the cannula of the concentrator was folded and hung on the machine. There was no protective bag in the room. During an observation and interview on 11/06/25 at 2:25 p.m., the nasal cannula and tubing of Resident #5 were in a plastic bag hung on the concentrator. RN C stated she kept it in the protective bag when observed in the afternoon that it was hanging on the oxygen concentrator without a bag. She stated Resident #5 used oxygen therapy every shift and was in the process of weaning off from it. RN C stated she knew protective bag helped to minimize contamination and thus respiratory infection. During an interview on 11/06/25 at 1:45pm, LVN A stated she was the charge nurse for Resident #1, Resident #3, and Resident #4. LVN A stated she was responsible for ensuring the nebulizer masks were in the protective bag. She stated it was her mistake and she did not ensure the masks were protected from contamination. She stated it was essential to minimize the risk of infection, especially respiratory infection. She stated she did not remember attending any in-service on this subject, however, was aware of the importance of it from her professional knowledge. During an interview on 11/06/25 at 1:50 p.m., LVN B stated she worked with Resident #2 this day. She stated Resident #2 handled the nebulizer independently and had the habit of keeping it anywhere. LVN B stated she did not know if Resident #2 was supervised at any time to make sure she stored the mask safely or was educated on the importance of storing in a protective cover . LVN B stated the necessity of storing it in protective cover was to protect the mask from contamination and it was the responsibility of the nurse to make sure it was done appropriately. She stated she did not remember if she received any in service in this regard at the facility. During an interview on 11/06/25 at 2:40 p.m., the DON stated it was a common practice that the residents used nebulizers by themselves and left them anywhere. When the investigator informed him that there were no protective bags available in any of the residents' rooms, he stated that was because the usual practice at the facility was storing them in a drawer. The DON stated one of the practices at the facility to reduce infection was minimizing contamination. He stated technically the nebulizer masks were to be cleaned and safely stored in the protective bags provided, however, in reality, this rarely happened. The DON stated there was no system in place to ensure the nurses were doing this properly and wanted to make sure the staff were diligent in this practice in the future. Record review of the facility's policy, titled Oxygen Administration, dated October 2010, had not reflected the necessity for storing oxygen/nebulizer tubing, cannulas, and facemasks in protective bags when not in use.Record review of web site https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf reviewed on 11/10/25 reflected: . Between uses: Store nebulizer parts in a dry, clean plastic storage bag. If the nebulizer is used by more than one person, keep each person's medicine cup, mouthpiece or mask, and tubing in a separate, labeled bag to prevent the spread of germs. Wipe the surface with a clean, damp cloth as needed. Cover nebulizer machine with a clean, dry cloth and store as stated in the instructions. Replace medicine cup, mouthpiece, mask, tubing, filter, and other parts as stated in the instructions or when they appear worn or damaged

Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents review for resident rights. RN A failed to notify Resident #1's family when a new medication order for antibiotics, to treat a urinary tract infection, was initiated on 06/14/2024. This failure put residents at risk for not having their representative notified and aware of their current medical status. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included retention of urine unspecified, pain unspecified, dementia (a general term for a decline in cognitive function that interferes with daily life) in other disease classified elsewhere, acute kidney failure (a sudden and rapid decline in kidney function). Face sheet also reflected Resident #1 had a Responsible Party. Review of the quarterly MDS assessment for Resident #1 dated 06/12/2025 reflected a BIMS score of 3, indicating severe cognitive impairment. It reflected he had an indwelling catheter. Review of the care plan for Resident #1 initiated 06/05/2025 reflected the following: [Resident #1] has ADL Self Care Performance Deficit relating to dementia, impaired limited mobility, he had impaired cognitive function/dementia or impaired thought processes related to dementia, Bims. Interventions included: Communicate with the resident/family/caregivers regarding residents' capabilities and needs. Review of Resident #1's MAR reflected: Sulfamethoxazole- Trimethoprim (Bactrim DS -is an antibiotic prescribed to treat various bacterial infection) Tablet 800- 160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days -Start Date- 06/14/2025. Review of Resident #'s progress notes dated 06/14/2025 at 10:05 pm created by RN A reflected: Note Text: The order you have entered Sulfamethoxazole-Trimethoprim Tablet 800-160 MG Give 1 tablet by mouth every 12 hours for UTI (E. coli) for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. Review of Resident #1's progress notes for 06/14/and 06/15/2025 did not reflect Resident #1's family was notified of a new antibiotic order for UTI. Review of Resident #1's NP's progress notes dated 06/16/2025 at 5:45 pm reflected: Acute UTI -urine cx collected 6/10/25, resulted 6/14/25 w/ +E. coli, 50-99k- d/t confusion and repeated falls treating for UTI- Bactrim DS 800/160 mg q12 ordered 6/14/25, ED 6/21/25 Review of Resident #1's progress notes dated 06/22/2025 at 10:58 am reflected Resident #1 was discharged home. During an interview on 07/09/2025 at about 2:19 pm, RN A stated she worked the 2-10 pm shift on the 700 and 800 halls. RN A stated her name was noted on Resident #1's antibiotic order because she confirmed the order put in by the NP. RN A stated the NPs usually put new orders in the computer and the nurses confirmed that they would start the order. RN A stated, I don't remember notifying the family or documenting on the antibiotic order. It was important to notify the family of new medication orders so they can know and sometimes the family would disagree with treatment plans. The family was always here, and we are always telling them things, maybe it slipped my mind. During an interview on 07/09/2025 at about 3:11 pm, the DON stated he expected the nursing staff to notify the family members for any new medication order before administering the medication because sometimes the family would decline the treatment plan, and to make sure they were aware and informed. The DON stated Resident #1's family was at the facility most of the time, and they were notified of changes in person. The DON stated he expected nursing staff to document on new orders. The DON stated he was aware that the NP spoke with Resident #1's RP a lot of time to discuss POC. The DON reviewed Resident #1's progress notes and noted there was no documentation of Resident #1's family being notified of new antibiotic orders. Review of the facility's policy titled Change of Condition revised January 2024 reflected: Policy: To identify and evaluate a change in condition and notify the Physician and Responsible Party when indicated. A significant change in Resident's status is any sign or symptom that is: Acute or sudden onset A marked change (i.e., more severe) in relation to usual signs and symptoms New or worsening symptoms3. Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained.

Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay and final status of discharge for three of three (Resident #1, Resident #2, Resident #3) reviewed for discharge summary. The facility failed to complete a discharge summary and recapitulation for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of not having complete records, necessary services, or information after permanent discharge from the facility. Findings included: Review of Resident #1's face sheet dated 05/19/2025 revealed an [AGE] year-old man admitted on [DATE] and discharged on [DATE] with diagnoses of erosive (osteo) arthritis (severe form of joint inflammation and bone erosion in hand), muscle weakness, cognitive communication deficit (problem with communication that results in impaired thought processes), mild cognitive impairment (condition where a person experiences more memory or thinking problems than expected for their age), and other symptoms and signs involving cognitive function and awareness (problems with memory, attention, and awareness of surroundings). Review of Resident #1's care plan dated 05/19/2025 reflected Resident #1 wished to be discharged home. Review of Resident #1's discharge MDS dated [DATE] reflected a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #1's physician orders reflected an order dated 04/29/2025 that indicated Resident #1 could discharge home on 04/30/2025 with home health and medications. Review of Resident #1's discharge instruction form reflected a date of 05/19/2025. Form included scheduled follow up appointments details of scheduled appointment with PCP for follow up and medication refills by 05/25/2025 despite Resident #1 discharge on 04/30/2025. Further review reflected dietary, skin, patient education/teaching, and patient /RP signature method used (electronic or hand written) was left blank. Review of Resident #1's recapitulation of stay form dated 04/30/2025 reflected complete this form when the resident is discharged . All items must be addressed. Nursing services section was incomplete and did not include physical function stats, if assistive devices were needed, if any therapies were planned at discharge, disposition of medications, and condition of skin. Activities section was. Dietary section was incomplete as well as rehabilitation services section. Review of Resident #1's progress notes from 04/07/2025 to 04/30/2025 reflected no discharge note was completed. Review of Resident #1's medical chart reflected no discharge summary was completed or uploaded. During an interview on 05/19/2025 at 11:06 AM, FM stated that at discharge of Resident #1 a nurse went into his room and kind of went over medications but did not provide a copy of medication list or the last time the medication was administered. The FM stated that medications were sent home at discharge, but no paperwork was provided. The FM stated that there was no follow up information provided at discharge and the paperwork that was provided was from Resident #1's hospital stay. Review of Resident #2's face sheet dated 05/19/2025 reflected an [AGE] year-old male admitted on [DATE] and discharged on [DATE] with diagnoses of generalized anxiety disorder (persistent and excessive worry), Parkinson's disease with dyskinesia (involuntary jerky movements as a side effect of some medications), polyneuropathy (disease affecting nerves and can cause weakness, numbness or pain), and unspecified fracture of left acetabulum (break in the socket of the hip joint). Review of Resident #2's discharge MDS dated [DATE] reflected a BIMS score of 0 which indicated severe cognitive impairment. Review of Resident #2's physician orders dated 05/13/2025 reflected Resident #2 to discharge to assisted living on 05/15/2025. Review of Resident #2's discharge instruction dated 05/15/2025 reflected an incomplete form that did not include dietary recommendations, skin condition, patient instructions/teaching, and the resident or RP signature method. Review of Resident #2's progress note dated 05/15/2025 reflected Resident #2 was discharged to an assisted living with belongings and medication was sent with driver. Review of Resident #2's medical chart reflected there was no discharge summary or recapitulation of stay completed or uploaded. Review of Resident #3's face sheet dated 05/19/2025 reflected an [AGE] year-old man admitted on [DATE] and discharged on [DATE] with diagnoses of aftercare following joint replacement surgery, unspecified cirrhosis of liver (condition characterized by chronic liver damage), hypokalemia (low potassium levels), and hyperlipidemia (high level of fats in the blood). Review of Resident #3's discharge MDS dated [DATE] reflected a BIMS of 15 which indicated no cognitive impairment. Review of Resident #3's physician orders revealed an order for Resident #3 to discharge on 05/12/2025 dated 05/09/2025. Review of Resident #3's recapitulation of stay dated 05/12/2025 reflected and incomplete document with only vitals and weight generated in the form. Review of Resident #3's medical chart reflected there was no discharge summary completed or uploaded. During an interview on 05/19/2025 at 2:06 PM, LVN B stated that she was made aware a resident was going to discharge from the SW. LVN B stated the SW let the nurses know and put in a discharge order. LVN B stated that the process to discharge a resident was to print out their orders, review medications and instructions with the resident or family. LVN B stated that she also counted the medications that were going to be sent with the resident. LVN B stated if the medication was less than a week's supply or the resident was not going to see their PCP for more than a week, then she asked the NP to send a prescription. LVN B stated that the resident or family signed discharge paperwork and instructions at discharge. LVN B stated that the discharge paperwork included medication list and what the medication was for, last time they took the medication and home health information. LVN B stated the discharge summary was started by the social worker and included where the resident was going, and the nurses inputted their part so it was completed together by the SW and nurse. During an interview on 05/19/2025 at 2:11 PM, RN A stated that she was made aware of a resident's discharge by the order the SW put in. RN A stated that medications were verified with the NP and the resident was sent with a week's worth of medication. If the resident did not have a week's supply for they did not have an appointment within a week to see their PCP then the NP may have provided a prescription. RN A stated during discharge medications were reviewed with the resident and reviewed with the resident or the family if the resident was not considered alert and oriented. There was a form that was reviewed and the family or resident was supposed to sign it. RN A stated the form included upcoming appointments, medication list and home health care information. RN A stated this also included a medication list and the last time a resident took the medications. RN A stated on the discharge summary the NP summarized their part and information was added by therapy and the SW. RN A stated the SW was supposed to put an order in for discharge and any DME the resident needed. During an interview on 05/19/2025 at 2:27 PM, the SW stated that as a team it was decided when a resident was medically stable to discharge or met their goals with therapy. The SW stated that the resident could have received notification of non-coverage and she spoke with the family and let them know an anticipated day. The SW stated a discharge list went out to management that included who was going to be discharged . The SW stated that it was also discussed during the morning meeting and confirmed the time and day of discharge and communication was made with the nurses. The SW stated at discharge residents should have received a discharge form, list of medications and any home health information that has been set up. The SW stated she opened the discharge form at the time she put in the discharge order and it had where the resident was going and home health information. SW stated nursing completed the rest of the form. The SW stated home health information was usually documented on the discharge instruction form. During an interview on 05/19/2025 at 3:56 PM, the DON stated that for discharge, medications were sent with the resident, a discharge summary a medication list, and any personal belongings. The DON stated the discharge summary included where the resident will be discharged to, background information of the resident and if they were going home with home health. The DON stated a recapitulation of stay was completed by the IDT members and they each had their own section. The DON stated it was definitely completed before discharge. The DON stated it was not usually sent with the resident and stated it was usually the discharge summary that was sent. During a subsequent interview on 05/19/2025 at 4:25 PM with the DON, he stated that the discharge summary was its own UDA and was specifically titled discharge summary. During an interview on 05/19/2025 at 4:50 pm, the ADM stated that at discharge she expected the resident to have had a clear plan of where the resident was discharging to, plan of care (home health care, hospice or sitter services), medication list, and equipment to have the tools the resident needed to be successful. The ADM stated she expected that the resident had all the documentation to shower their baseline, where they began and ended and if they reached their goals so it painted a clear picture. The ADM stated the SW was responsible to ensure the discharge summary and recapitulation was initiated and completed. The ADM stated that there was not a process that checked that the information was completed other than a 30-day call back process and discussing any hospitalization after discharge. The ADM stated she expected discharge information to be in PCC so that the facility was aware of where the resident went and who is following them (home health/ hospice). Review of facility policy titled Discharge Summary and Plan dated October 2022 reflected when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. Further review reflected the discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations. Discharge summary should included, current diagnoses, medication history, course of illness, physician and mental functional status and ability to perform ADLs. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary.

Based on observations, interviews, and record review, the facility failed to provide routine and/or emergency drugs and biologicals to its residents for three of (Resident #21, Resident #345, and Resident #90) four residents reviewed for pharmacy services. The facility failed to ensure Resident #21, Resident #345, and Resident #90's antibiotic medicine were administered daily as ordered. The facility failed to administer antibiotic medicine 02 times and at the correct time 21 times for Resident #21. The facility failed to administer antibiotic medicine 04 times for Resident #345. The facility failed to administer antibiotic #1 medicine 01 time and at the correct time 06 times for Resident #90. The facility failed to administer antibiotic #2 medicine at the correct time 16 times for Resident #90. This failure could place residents at risk of not receiving necessary preventative measures and adversely affect a resident's condition. Findings include: Review of Resident #21's face sheet revealed a [AGE] year-old male admitted [DATE] with diagnoses of Methicillin Susceptible Staphylococcus Aureus Infection (MSSA) (bacterial infection also known as a staph infection), Unspecified Site, Acute and Subacute Infective Endocarditis (SBE) (germs such as bacteria enter the bloodstream and attack the lining of the heart valves.), and Osteomyelitis of Vertebra, Lumbar Region (bacteria or fungi infect your spine bones). Further review revealed Resident #21 was discharged to his family on 04/08/2025. Review of Resident #21's admission MDS dated [DATE] revealed resident had IV Medications as an infection treatment. Review of Resident #21's physician's order dated 03/20/2025 revealed to administer 2 grams intravenously every 8 hours to help reduce complications related to infections and abscesses resolution, IV - PICC - dressing change, IV - tubing change, IV flush SASH method (Saline-Administration-Saline-Heparin used for flushing and delivering medicine to IV (intravenous) every shift. Further review revealed additional administration order dated 03/24/2025 revealed to administer ceFAZolin Sodium Injection Solution Reconstituted (treats many types of bacterial infections) 2 GM intravenously every 8 hours. Review of Resident #21's initial care plan reflected Resident #21 was at risk for complications related to infections. Goal included administering anti-viral and antibiotics as per MD orders, maintaining universal precautions when providing resident care, administering intravenous fluids as prescribed, changing tubing and site dressing as ordered, checking IV site as ordered and to observe for signs of infection, maintain rate of infusion as ordered, re-site IV per IV Therapy Protocol. Review of Resident #21's administration report dated March 2025 and April 2025 reflected two doses of antibiotics were not administered and 21 doses were administered late. ceFAZolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously every 8 hours (12:00 AM, 8:00 AM, and 4:00 PM) Date Scheduled Administered Time 03/21/2025 8:00 AM 2:52 PM 03/22/2025 8:00 AM not administered 03/21/2025 4:00 PM 5:30 PM 03/22/2025 12:00 AM 3:29 AM 03/23/2025 8:00 AM 11:56 AM 03/24/2025 12:00 AM 6:52 AM 03/24/2025 8:00 AM 1:14 PM 03/25/2025 8:00 AM 1:56 PM 03/25/2025 4:00 PM 6:36 PM 03/26/2025 12:00 PM 2:42 AM 03/26/2025 8:00 AM 12:11 PM 03/26/2025 4:00 PM 6:49 PM 03/27/2025 8:00 AM not administered 03/27/2025 4:00 PM 8:12 PM 03/31/2025 12:00 AM 5:48 AM 04/02/2025 8:00 AM 2:33 PM 04/02/2025 4:00 PM 5:24 PM 04/03/2025 8:00 AM 2:37 PM 04/03/2025 4:00 PM 8:04 PM 04/04/2025 8:00 AM 3:48 PM 04/05/2025 4:00 PM 8:35 PM 04/07/2025 12:00 AM 5:07 AM 04/07/2025 8:00 AM 4:02 PM In an interview on 04/10/2025 at 11:54 AM LVN UM stated the expectation for admission nurses is to complete the initial assessment for new residents. She stated she is responsible for conducting head to toe assessment, entering diagnoses and medications received from discharging hospital or hospice into EMR. She stated discharge orders are usually received ahead of time and medications will be ordered before admission of resident or can go directly to the pharmacy. She stated when the charge nurse receives the medication list they will send to the NP or MD. She stated that antibiotics can usually be pulled from Pyxis system for quick access. She stated for narcotics the process is to reach the NP to send orders to the pharmacy and typically can be delivered within 30 minutes of orders being entered. In an interview on 04/10/2025 at 1:53 PM DON stated the expectations are for nurses to complete nursing admission assessments within 24 hours, entering medication orders, adding progress note at admission, transferring skill status (why at facility) and adding anything else that is pertinent to the resident admitting into the facility. He stated this also includes obtaining consent to treat resident, obtaining consent for bed rails, with an expectation of completing all admissions tasks within 24 hours. He stated that once medication orders are entered into the EMR system they are usually delivered within the first few hours after admission. He stated the more difficult medications that require triplicates (narcotics) would require an access code from the pharmacy to gain access to Pyxis machine. He stated antibiotics are usually easy to get ordered and not considered a difficult medication. He stated if there are medications not showing up on the MAR, not administered or missed then a nursing note would be documented under progress notes and he and the provider would be notified. In a phone interview on 04/10/2025 at 5:00 PM LVN A stated the MAR and physician orders are followed and provide staff with directions as to the time the dose should be administered and when the last dose was administered by staff. She stated the MAR outlines specific times the medication should be administered. She stated if medications are not given on time or administered this could cause the residents health problems or additional concerns. She stated the expectation is if medications could not be administered staff must make a note in the medical chart and notify the DON and NP or MD that it was missed. In an interview on 04/10/2025 at 6:00 PM DON and ADON stated the procedure for missed medications is to document in the chart and notify the DON and NP immediately. Both were not informed of any missed or late medications for Resident #21. Findings include: Review of Resident #345's face sheet reflected a [AGE] year-old female admitted [DATE] with diagnoses of Pneumonia, (air sacs in lungs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing), Hypo-Osmolality (lower than normal levels of electrolytes, proteins, and nutrients in the blood) and Hyponatremia (low concentration of sodium in the blood), and Noninfective Gastroenteritis (lining of the intestines is inflamed and irritated) and Colitis (inflammation of the lining of the colon). Review of Resident #345's admission MDS dated [DATE] reflected resident has active diagnosis of infection, pneumonia. Review of Resident #345's physician's order dated 04/08/2025 reflected to administer amoxicillin oral capsule 500 MG, 1 capsule by mouth three times a day related to pneumonia unspecified for 3 days. Review of Resident #345's clinical summary report dated 04/6/2025 generated in Epic (software that communicates the EMR between the facility and the hospital and uploaded into facility's primary EMR software on 04/06/2025 listed active medications at discharge, which included amoxicillin 500 mg capsule, take 1 capsule by mouth 3 times daily for 3 days, 9 capsule dispense quantity, 04/06/2025 start date, 04/09/2025 end date. Further review reflected that the hospital sent the physician's orders for Resident #345's antibiotics directly to the pharmacy on 04/06/2025. Review of Resident #345's hospital discharge report provided to resident dated 04/06/2025 reflected a list of Resident #345's medications at discharge and this list did not include antibiotics. Further review reflected this report was the limited version that the hospital typically provides to a patient at discharge. Review of Resident #345's initial care plan dated 04/07/2025 reflected Resident #345 had an infection and interventions included administering antibiotic as per MD orders. Further review reflected care plan revision on 04/08/2025 identified antibiotic as ordered through 4/11/2025. Review of Resident #345's nursing admission assessment dated [DATE] reflected admission was at 12:45 PM, vitals were taken at 5:45 PM and infection care plan listed: Focus: The resident has infection. Goal: The resident will be free from complications related to infection through the review date. Intervention: Administer anti-viral as per MD orders. Intervention: Administer antibiotic as per MD orders. Intervention: Follow facility policy and procedures for line listing, summarizing, and reporting infections. Intervention: Maintain universal precautions when providing resident care. Interventions: Monitor/document/report to MD changes in behavior. Review of Resident #345's administration report dated April 2025 reflected four doses of antibiotics were not administered. Amoxicillin Oral Capsule 500 MG Give 1 capsule by mouth three times a day (8:00 AM, 12:00 PM, and 8:00 PM schedule listed on MAR) Date Scheduled Administered Time 04/06/2025 8:00 PM not administered 04/07/2025 8:00 AM not administered 04/07/2025 12:00 PM not administered 04/07/2025 8:00 PM not administered In an interview on 04/09/2025 at 10:55 AM LVN UM stated the admission nurse had medications ordered from the pharmacy immediately when Resident #345 was admitted . She stated there are no concerns with medications being delivered for any resident. The facility's protocol is to pull medications from reserves in Pyxis (pharmacy automation). She stated routine and non-routine medications can be easily and quickly filled. She stated the more challenging medications for example pain medication where a triplicate is required there would be a slight delay (few hours) and orders would be sent to Pyxis for distribution and a code would be provided to facility staff to access. LVN UM stated nurses are expected to review the resident's MAR for next dose and if there is a specific timeframe outlined for administration then this is what the nurse will follow for administration. She stated the protocol for missed or late medication administration is to document record and immediately notify the DON and NP or MD. She stated there could be a negative impact on the resident's progress if medication is missed or late. In an interview on 04/09/2025 at 03:26 PM ADON stated she didn't receive communication from the NP for orders for Resident #345. She stated the protocol is to obtain hospital discharge orders and at once notify the NP for reconciliation. She stated all nurses are expected to review the resident's MAR closely for scheduled times of all medications. She stated medications that are missed or late can affect resident's progress and stated the expectation is for nurses to report all medication errors (including missed or late) to DON and NP or MD. In an interview on 04/09/2025 at 4:15 PM DON stated the hospital discharge report provided to the resident includes the list of medications used to reconcile with the NP. The DON stated the NP reviewed the medication list by phone and provided verbal orders to administer. He stated this medication list did not include an antibiotic. The DON stated the protocol is for the admission nurse to use the limited hospital discharge report to reconcile medications with the NP or MD and if the NP does not agree with a medication order she will not provide a verbal order to administer, and a nursing note would be entered into EMR documenting this action. He stated that facility medications can be distributed and delivered quickly for new admissions and refills. He stated the more complex medications for example-controlled substances which require a triplicate will take a bit more time and require Pyxis codes and access. He stated typically it is a few hours (less than 4) from admission time to delivery of medication for a new admit. In an interview on 04/10/2025 at 11:30 AM LVN A stated the expectation is for all charge nurses to handle admissions and readmissions as a collective effort between LVNs and RNs. She sated nurses are provided in-services conducted by unit supervisors, the DON and ADON. She stated she is provided with an admission checklist of everything to be included in the admissions process. She is also responsible for assessing resident, providing a welcome packet of information, completing vitals and head-to-toe assessment, reconciling medication with the NP or MD available, inputting medications into EMR, and following up with pharmacy to confirm delivery. She stated that medication reconciliation is completed upon admission by using hospital discharge paperwork presented by the resident at admission. In an interview on 04/10/2025 at 11:54 AM LVN UM stated the expectation for admission nurses is to complete the initial assessment for new residents. She stated she along with all admission nurses are responsible for conducting head to toe assessment, entering diagnoses and medications received from discharging hospital or hospice into EMR. She stated discharge orders are usually received ahead of time and medications will be ordered before admission of resident or can go directly to the pharmacy. She stated when the charge nurse receives the medication list they will send to the NP or MD. She stated that antibiotics can usually be pulled from Pyxis system for quick access. She stated for narcotics the process is to reach the NP to send orders to the pharmacy and typically can be delivered within 30 minutes of orders being entered. In an interview on 04/10/2025 at 12:42 PM LVN UM stated there have been some issues with antibiotic orders coming over in their EMR system that the administration team is aware of and are working on. She would not provide additional details. In an interview on 04/10/2025 at 1:53 PM DON stated the expectations are for nurses to complete nursing admission assessments within 24 hours, entering medication orders, adding progress note at admission, transferring skill status (why at facility) and adding anything else that is pertinent to the resident admitting into the facility. He stated this also includes obtaining consent to treat resident, obtaining consent for bed rails, with an expectation of completing all admissions tasks within 24 hours. He stated that once medication orders are entered into the EMR system they are usually delivered within the first few hours after admission. He stated the more difficult medications that require triplicates (narcotics) would require an access code from the pharmacy to gain access to Pyxis machine. He stated antibiotics are usually easy to get ordered and not considered a difficult medication. He stated if there are medications not showing up on the MAR, not administered or missed then a nursing note would be documented under progress notes and he and the provider would be notified. In an interview on 04/10/2025 at 2:54 PM DON stated Resident #345's discharge orders were not present at admission. He stated Resident #345 did not present at the facility with antibiotics or orders for antibiotics. He stated the NP was notified of orders and after review of Resident #345's medical records she noted resident completed an antibiotic regimen in the hospital. He stated Resident #345's daughter notified the charge nurse that Resident #345 should be on a 3-day antibiotic. He stated that he provided daughter with the hospital's discharge instructions and antibiotics were not on the list of medications ordered. He stated a charge nurse notified him that an antibiotic was delivered for Resident #345 on 04/07/2025. He stated it appeared the hospital sent the antibiotic orders directly to the pharmacy to be filled. He stated the charge nurse notified the NP of antibiotic delivery and she was confused by this. He stated the NP reviewed Resident #345's medical history and discharge summary and afterwards she approved the administration of antibiotics. He also stated when the admission charge nurse was completing the admission assessment on Resident #345 it was done in error, as the resident did not have an antibiotic listed. He stated there seems to be a communication issue between Epic and PCC software and he is not sure why not sure why medical records staff are pulling the Epic report when the facility's process is to use discharge report directly from hospital or resident. In an interview on 04/10/2025 at 3:19 PM ADON stated she wanted to provide the surveyor with record review help and stated the facility gets a direct email from the discharge planner/coordinator from the hospital and that is what was received for Resident #345. She stated that the other clinical summary report received in the facility's EMR system is not used by admission nurses to reconcile medication with NP or MD. She stated the discharge clinicals vs. the discharge summary are two different reports and the facility staff are trained to review the discharge summary to reconcile medications. And she stated the admission nurse LVN B may have forgotten to uncheck the antibiotic box on the admission assessment or may have checked antibiotics because she was aware that Resident #345 had been administered antibiotics at the hospital earlier in the day and selected this option in error and not because she reviewed antibiotics on any discharge forms received. In an interview on 04/10/2025 at 4:15 PM DON stated the hospital representative/coordinator stated the discharge paperwork typically provided to patients at discharge is the same paperwork the facility receives and uses for reconciling medications. He stated the coordinator would need to speak with their legal team to confirm if a written statement noting this information could be provided to facility for survey purposes. In a phone interview on 04/10/2025 at 5:00 PM LVN A stated the MAR and physician orders are followed and provide staff with directions as to the time the dose should be administered and when the last dose was administered by staff. She stated the MAR outlines specific times the medication should be administered. She stated if medications are not given on time or administered this could cause the residents health problems or additional concerns. She stated the expectation is if medications could not be administered staff must make a note in the medical chart and notify the DON and NP or MD that it was missed. In a phone interview on 04/10/2025 at 5:39 PM NFA stated the facility receives the same discharge paperwork given to the patient at the hospital. He stated the facility will also have access to medical documentation as the full chart is available to the facility in Epic. He stated the after summary is what is followed for discharge summary orders. He stated he cannot comment on whether the facility should be accessing only the hospital summary or in addition to the clinical chart. He stated the hospital's field representative directs the facility to use the hospital summary. He stated he cannot speak on facility only reviewing the discharge summary report as they have access to the clinical chart as well. He stated he would have to speak with the case manager at the hospital to gain more insight as to what the facility should be accessing for resident care services and after care. In an interview on 04/10/2025 at 6:00 PM DON and ADON stated the procedure for missed medications is to document in the chart and notify the DON and NP immediately. Both were not informed of any missed or late medications for Resident #345. In an interview on 04/10/2025 at 6:01 PM the ED stated the expectations for new admissions are for the charge nurses to completing the new admission assessment and orders. She stated the charge nurses are the primary staff accepting new admissions, but ADON and DON can also help with this task if necessary. She stated the admission nurses are responsible for completing a head-to-toe toe assessment of new admit and reconciling medications. She stated the nurse is responsible for entering orders the hospital may send to the facility. She stated nurses are responsible for reconciling orders from discharge paperwork, against what is received directly in EMR. She stated that typically when a new resident arrives a discharge summary from the hospital will accompany them. She stated some discharge information can be collected via phone with during a nurse-to-nurse report and then documented in the EMR. Review of Resident #90's face sheet reflected [AGE] year-old female admitted [DATE] with diagnoses of Osteomyelitis of the vertebral, sacral, and sacrococcygeal region (rare spinal infection that can occur due to injury, surgery, or spread from another part of the body through the bloodstream), Displaced Intertrochanteric Fracture of Right Femur (hip fracture), and Muscle Weakness (lack of muscle strength). Review of Resident #90's admission MDS dated [DATE] reflected resident had IV Medications as an infection treatment. Review of Resident #90's initial care plan reflected Resident #90 was at risk for complications related to infections. Goal included administering anti-viral and antibiotics as per MD orders, maintaining universal precautions when providing resident care, administering intravenous fluids as prescribed, changing tubing and site dressing as ordered, checking IV site as ordered and to observe for signs of infection, maintain rate of infusion as ordered, re-site IV per IV Therapy Protocol. Review of Resident #90's nursing admission assessment dated [DATE] reflected admission assessment was effective at 5:44 PM, vitals were taken at 4:10 PM and infection care plan listed: Focus: The resident has infection. Goal: The resident will be free from complications related to infection through the review date. Intervention: Administer anti-viral as per MD orders. Intervention: Administer antibiotic as per MD orders. Intervention: Follow facility policy and procedures for line listing, summarizing, and reporting infections. Intervention: Maintain universal precautions when providing resident care. Interventions: Monitor/document/report to MD changes in behavior. Review of Resident #90's physician's orders dated 03/26/2025 reflected to administer Daptomycin Intravenous Solution Reconstituted Use 650 mg intravenously one time a day. Review of Resident #90's administration report dated March 2025 and April 2025 reflected 01 dose of antibiotics were not administered and 06 doses were administered late. DAPTOmycin Intravenous Solution Reconstituted (Daptomycin) Use 650 mg intravenously in the evening (5:00 PM schedule listed on MAR) Date Scheduled Administered Time 3/27/2025 5:00 PM 9:27 PM 03/28/2025 5:00 PM not administered 3/29/2025 5:00 PM 10:33 PM 3/30/2025 5:00 PM 9:17 PM 4/01/2025 5:00 PM 8:00 PM 4/04/2025 5:00 PM 7:27 PM 4/05/2025 5:00 PM 7:43 PM Review of Resident #90's administration report dated March 2025 and April 2025 reflected 16 doses of antibiotics were administered late. Meropenem Intravenous Solution Reconstituted 2 GM (Meropenem) Use 2 gram intravenously every 8 hours (12:00 AM, 8:00 AM, and 4:00 PM schedule listed on MAR) Date Scheduled Administered Time 3/27/2025 12:00 AM 2:07 AM 3/27/2025 4:00 PM 7:50 PM 3/28/2025 4:00 PM 6:32 PM 3/29/2025 4:00 PM &

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. Some food items were not labeled at all. - The grease in the fryer was dirty. - Drawers where the serving utensils were stored were not clean with debris in in the drawer. - Staff serving food in hall 100 were not sanitizing their hands before getting food trays to take to the resident. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness. Findings include: Observation on 4/08/2025 at 9:15 am of the walk-in refrigerator reflected the following: - Lemons in a box were dated 3-17-2025 with no discard date. - Lemonade in a serving container dated 2-10-2025 was expired. - Lettuce dated 4-7-2025 with no discard date. - Cucumbers in a box dated 3-10-2025 with no discard date. - Raw meat in a pan covered in plastic dated 4-6-2025 with no discard date. - Raw ground Sausage dated 4-7-2025 with no discard date. - Puree meat dated 4-7-2025 with no discard date. - Brown Puree that was not labeled in a metal container with plastic wrap dated 4-5-2025. - Flour tortillas with an expiration date of 4-16-2025. Observation on 4/08/2025 at 9:25 am of the kitchen reflected the following: - Serving utensils were in a drawer under a table that had food debris in the bottom of the drawer. - The fryer grease appeared old, with a lot of food debris on the top of the grease. Observation on 4/08/2025 at 11:30 am KC taking food temps reflected the following: - The KC did not take temperatures of the fried chicken, mixed vegetables, or pureed bread. Observation on 4/08/2025 at 12:35 PM on the 100 hall reflected the following: CNA E was not sanitizing their hands in between grabbing food from the food cart and taking it to resident's room. CNA did this several times on the hall before taking residents their food. Interview on 4-10-2025 at 2:30 PM, KC F stated that all food was not temped before it is served to the facility's residents. KC F said the drawer where the serving utensils are stored should be cleaned once per week. KC F said a walk-through is done every morning in the pantry, walk-in fridge, and walk-in freezer to check for out-of-date products. KC F said if he finds out-of-date products, he will inform the supervisor about them and discard the out-of-date food. KC F said if the grease is not changed once a week, it can make the food taste bad. KC F said that if residents are served food that is outdated or not temped, then residents can get sick with a food-borne illness. Interview on 4-10-2025 at 2:40 PM, KC G said the pantry walk-in and freezer should be checked for out-of-date products daily. He said the drawers containing the serving utensils are cleaned after each shift. If he finds out-of-date products, he will inform the supervisor and discard the food. KC G said that when he is cooking, he temps the food after it is cooked and before it is served to the residents. KC G said that all cooks are responsible for changing the grease when it is dirty. KC G said that if food is not temped and expired food is used, residents can get a food-borne illness and get sick. Interview on 4-10-2025 at 2:40 PM, the KA said the kitchen is checked twice weekly for outdated food. KA said the drawers containing serving utensils are cleaned daily. The KA said he does not do temperatures on food. KA said that residents could get food poisoning if outdated food is served to residents. Interview on 4-10-2025 at 2:48 PM, the DM stated that all food should be tempted before serving it to the residents. The DM said that the grease in the fryer is changed once or twice a week, depending on what is cooked in the fryer. The DM said that the cooks are responsible for changing the grease in the fryer. The DM said the drawers are cleaned weekly or as needed. The DM said that serving utensil drawers should be checked regularly for cleanliness. The DM said there could be cross-contamination if the drawers are not cleaned. The DM said residents could get sick if outdated food is served or if the temperature of the food is not taken before serving it to the residents. DM manager said that food that is opened and not in the original package should have a discard date. DM was made aware of the items in the walk-in cooler that there were items in boxes that did not have a discard date. Interview on 4-10-2025 at 2:58 PM, the RDM said staff should check for outdated food once a week. She said the temperature of all prepared food should be taken before serving it to the residents, and the grease in the fryer should be changed weekly. The RDM said that the drawers with clean utensils are expected to be cleaned regularly. The RDM said that if food is not temped and outdated food is served to residents, they could get sick. Interview on 4-10-2025 at 3:23 p.m., CNA D said that when serving residents on the hall, she sanitizes her hands each time she gets another tray for a resident to prevent contamination. CNA D said that if she sees other staff doing it the wrong way, they will correct them. Interview on 4-10-2025 at 3:40 p.m., CNA E said that she cleans her hands between each meal she serves the residents are not clean, it would be an infection control issue. CNA E said that she has been trained on food safety and infection control. Interview on 4-10-2025 at 3:40 p.m., the RN said she sanitizes her hands before taking each resident's meal. If hands are not sanitized, the resident could get an infection. The RN said that she has had food safety training. Interview on 4-10-2025 at 5:58 PM, the ED stated that kitchen staff should take the temperature of all prepared food before it is served to the residents. The ED also said that kitchen staff should check for outdated food regularly to ensure that no outdated food is being served to residents. The ED said that the kitchen should be cleaned regularly. ED said the residents risk getting sick if these things are not done. The ED said that staff should sanitize their hands between food trays that are delivered to the residents. Residents' tickets should be checked with the tickets to make sure the resident is getting the correct food. Food is supposed to be temped after cooking and before service. Outdated food is to be checked daily or weekly and discarded. Depending on the food cooked, the grease should be changed twice weekly. Drawers should be cleaned daily to prevent contamination. Record Review Food Temperature Policies: 1. All hot food items must be served to the Resident at the temperature of at least 140 degrees F at the time the Resident receives the food. 4. Cooking temperatures must be reached and maintained according to regulations. Laws and standardized recipes while cooking.

Based on interview and record review, the facility failed to ensure the drug regiment review recommendations from the pharmacy consultant were received and acted upon for 1 (Resident # 144) of 4 residents reviewed for drug regimen review. The facility failed to follow their policy regarding the pharmacy consultant and did not follow up on new admission pharmacy consultant recommendations dated 3/28/25. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration. Findings included: Review of Resident # 144's admission record dated 4/10/25 reflected an [AGE] year-old female admitted on [DATE]. Resident #144 had diagnoses of traumatic subdural hemorrhage with loss of consciousness of unspecified duration (brain bleed with loss of loss of consciousness), fracture of sacrum (fracture of bone that connects the spine to the pelvis), type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar levels), muscle weakness, fracture of occiput left side (skull fracture on the left side), cognitive communication deficit (difficulties with communication that arise from problems with cognitive processes like attention and memory), hypothyroidism (underactive thyroid), hyperlipidemia (increased fat particles in the blood), hypertension (high blood pressure), pain, and vitamin D deficiency. Review of Resident # 144's admission MDS dated [DATE] reflected a BIMS score of 5 indicating severe cognitive impairment. Review of section I active diagnoses reflected traumatic brain dysfunction as primary admitting diagnosis. Review of section J health conditions reflected for pain management Resident # 144 received scheduled pain medication regimen. Further review of pain assessment reflected no pain presence for last 5 days. Review of Resident # 144's care plan dated 3/27/25 and revised on 4/8/25 reflected problem of Resident # 144 is at risk for pain and is on pain medication therapy as ordered. Interventions include administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, ask physician to review medication if side effects persist, review pain medication efficacy, monitor/document/report PRN adverse reactions to analgesic (pain reliever) therapy, and monitor for increased falls. Review of Resident # 144's MAR for April dated 4/10/25 reflected record of medication administration of the following medications and dosages with start date of 3/27/25 for Lipitor 40 mg 1 tablet by mouth at bedtime, metformin 500 mg give 1 tablet by mouth two times a day with recorded administration times of 9:00 am and 9:00 pm with start date of 3/30/25, Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain with start date of 3/27/25, cholecalciferol oral tablet 125 mcg (5000 UT) give 2 tablets by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday with start date of 3/31/25. Review of Resident # 144's Clinical physician orders revealed orders for metformin 500 mg give 1 tablet by mouth two times a day with a start date of 3/30/25, cholecalciferol oral tablet 125 mcg (5000 UT) give 2 tablets by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday with start date of 3/31/25, Lipitor 40 mg 1 tablet by mouth at bedtime with a start date of 3/27/25, and Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain with start date of 3/27/25. Interview on 4/10/25 at 12:26 PM with the DON regarding the pharmacist's recommendations concerning Resident #144 the DON stated, that yes, Resident # 144's recommendations were missing from the pharmacy binder for the month of March. The DON stated he contacted the Pharmacist on 4/10/25 and the Pharmacist responded that Resident # 144 had been reviewed and recommendations sent on 3/28/25. The DON stated he told the Pharmacist that he never received the 3/28/25 email of recommendations. The DON stated the Pharmacist responded they would check the emails that were sent to the DON and saw that the 3/28/25 email did not go through. The DON stated the Pharmacist re-sent email with 3/28/25 recommendations on 4/10/25. The DON stated he received the recommendations from the pharmacist for 3/28/25 on 4/10/25. The DON stated after he received the recommendations, he took them to the NP for review and signatures. The DON stated he was unsure what the contract for pharmacy stated as to who checked to ensure recommendations were received or as to how often that was occurring. Review of Resident # 144's pharmacist recommendations dated 3/28/25 reflected to change metformin to BID with meals -breakfast/dinner per manufacturer, consider 30 day hold on Lipitor for [AGE] year old with anorexia (Megace daily), due to fracture, being calcium 600mg/Vitamin D 400IU 1 tab BID, set 14 day stop to PRN Norco for post fracture pain. Further review of pharmacist note dated 4/10/25 to the attending physician reflected the physician declined setting a 14 day stop to prn Norco, the physician wrote they would consider the 30 day hold on the Lipitor, and the physician agreed with the recommendation for the calcium/Vitamin D. Interview on 4/10/25 at 5:53 PM the ED stated it was her expectation the Pharmacist came in person or communicated through email monthly to the DON their recommendations. The ED stated the DON would be responsible for ensuring communication from the pharmacy is received and implemented. The ED stated it could negatively affect a resident if medication recommendations are not received and implemented. The ED stated the new admission orders and changes to orders are discussed in the daily morning meeting (stand up) with the DON, ADON, and unit manager and at the end of day meeting (stand down) the completion status is updated concerning any medication recommendations and reviews. Attempted telephone interview with the Pharmacist on 4/11/25 at 4:30 pm and 4/17/25 at 11:55 am revealed no answer and a message left with contact information. Call not returned. Review of the Consultant Pharmacist policy with a revision date of April 2019 reflected under policy interpretation and implementation. 5. The consultant pharmacist will provide specific activities related to medication regimen including: a. a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. b. appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated.

Based on interviews and record reviews the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 7 residents reviewed for accidents and hazards. CNA A failed to transfer Resident #1 received assistance with the mechanical lift on 12/14/2024. This failure could result in residents receiving injuries. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began. Findings included: Record review of Resident #1's Face sheet dated 12/31/2024 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit (problems with communication), pressure ulcer of right heel (wound on heel), dysphagia (difficulty swallowing), difficulty walking, repeated falls, lack of coordination, osteoarthritis (joint disease), cerebrovascular disease (a range of conditions that affect the blood flow to the brain), nutritional deficiency,. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, indicating she was moderately impaired. Her Functional Status reflected she required substantial/maximal assistance with transfers. Record review of Resident #1's care plan, dated 10/7/24, reflected she was a mechanical lift transfer. The care plan also revealed two persons assist with all transfers. Record review of facility investigation dated 12/20/2024 revealed CNA A did not see anyone in the area, so she attempted to transfer the resident from her wheelchair to bed by herself. She was unable to transfer the resident and lowered the resident to a sitting position on the floor. It was noted that the resident was not injured at the time of incident. Record review of employee coaching and counseling record dated 12/14/2024 revealed CNA A documented under employee remarks Resident did not fall! I tried to pivot the resident from chair to bed. When at the bedside resident begun to go down, so I sat the resident on the floor and went for help. During an interview with Residents on 12/31/2024 starting at noon revealed that Residents did not have any concerns about their care. Residents stated the staff transfer them correctly and were not afraid of being transferred by staff. A telephone interview with CNA A attempted on 12/31/2024 at 3:49pm was unsuccessful. She did not call surveyor back. A telephone interview attempt with CNA A on 01/14/2025 at 2:05 pm was unsuccessful; at 5:26 pm another attempt was made to CNA A; she answered the telephone. CNA A stated she had not had any in-services, but she did state she was trained on how to operate a mechanical lift. CNA A then stated she was at work, and she would contact me back. No return call was received. During an interview with CNA B on 12/31/2024 at 3:15pm revealed he had been trained on transfers, abuse and neglect and fall prevention. He said he was at the nurse's station when CNA A came to get him and asked him for help. He said the resident had come back from being out on pass at round 9:00pm. He said that CNA A asked him for help at 9:30pm. He said the mechanical lift sling was under the resident, and he went to get the mechanical lift. He said when he got to the room Resident #1 was sitting on the floor. He said he told CNA A she needed to have the nurse evaluate the resident before they moved her. He said Resident #1 complained of pain in her left shoulder and told the nurse she had the pain before the fall. He said Resident #1 was a two-person mechanical lift transfer. During an interview with LVN C on 12/31/2024 at 3:48pm revealed she had been trained on transfers, abuse and neglect and fall precautions. She said the resident came back from pass with her family. He said the CNA A went to put the resident in bed and tried to transfer the resident by herself. He said CNA A knew the resident was a two-person mechanical lift transfer. He said CNA A came and told him what happened, and she needed to be assessed. He said when he arrived at the room to assess Resident #1, she was sitting on the side of the bed on her buttocks. LVN C performed a head-to-toe assessment on Resident #1 including vitals and pain assessments, ROM to all extremities with no negative findings. LVN C stated he asked the resident was she in pain and she stated she was hurting but she had been hurting all day. LVN C stated after the he completed the assessment of the resident, LVN C along with CNA A and CNA B transferred the resident with the mechanical lift to the bed. LVN C then notified the NP, RP and DON of the incident. LVN C stated a while back (no specific time given) that the resident wore a sling on her left arm. LVN C stated Resident # 1 did not complain of any pain the rest of the night. During an interview with the ADM on 12/31/2024 at 4:17pm revealed she and staff have been trained on transfers. She said the staff can find the transfer status of a resident in their care plan. She said CNA A did not see anyone in the hall or at the nurse's station to help transfer Resident #1. She said CNA A told her she thought she could transfer the resident by herself. She said CNA A realized she made a mistake and lowered the resident to the floor and went to get CNA B to help her. She said CNA B told CNA A she needed to have the nurse evaluate Resident #1 before transferring her since she was sitting on the floor. ADM stated LVN C advised her Resident #1 advised him she had been hurting since earlier in the day. The ADM stated she received a call from the SW on 12/15/2024 and she stated the family decided Resident #1 will not be returning to the facility. During an interview with the DON on 01/14/2025 at 1:50pm revealed Resident #1 was out on pass with her family on or about 4:30/5:00pm and returned to the facility at 9:00pm. He received a call from LVN C that CNA A attempted to transfer Resident #1 to the bed by herself and without the mechanical mechanical lift. DON stated LVN C stated CNA A advised him she did not see anyone to assist her with transferring the resident. DON stated Resident #1 has been a 2 person assist since he has been employed at the facility for the last 2 years. DON stated he was advised Resident #1 ended up on the floor because CNA A attempted to lift resident by herself, and she could not hold her. DON stated Resident #1 always complained on/off about left arm pain. DON stated when you reposition her you must be careful. DON stated after the incident occurred, he spoke with the RP and advised her they would be reporting the improper fall incident to the state. DON stated they decided to do an x-ray because Resident #1 started to complain of the arm pain the next day. The DON stated he contacted the RP and did not want Resident #1 to go to the hospital because it was late, and she did not want her to be disoriented due to her having dementia. DON advised her of the results of the x-ray and Resident #1 was complaining of arm pain and it was protocol to send a resident to the hospital for further care. DON stated there is always someone around that could have assisted and she was just impatient. DON stated in-services on Mechanical Lift, Abuse and Neglect, and timely Incident Reporting, Prevention of Falls and Significant Injuries by Utilizing Daily Care guides. DON stated CNA A was off on 12/15/2024 and returned to work on 12/16/2024 in which she was suspended pending the investigation and terminated on 12/18/2024. DON stated the self-report was completed, pain assessment completed, interviewed staff of abuse and neglect, also filled out the forms with the resident if they witness or happened to have had abuse or neglect and interview the staff on abuse and neglect. DON stated Resident #1 was a heavy wetter and wondered how the family handled Resident #1 when out on pass regarding incontinent care. DON stated the resident would be out with the family at a minimum of 4 to 5 hours. During an interview with the RP on 01/14/2025 at 1:10pm revealed Resident #1 was out on leave with her sibling, and she was returned to the facility at 9:00pm on 12/14/2024. RP stated prior to Resident #1 leaving out on pass, she stated CNA A was rude to her. Upon Resident #1 return and CNA A trying to place her in the bed, Resident #1 was advised to hug CNA A so she can pick her up. RP stated Resident #1 figured she was trying to be nice to her because she was rude to her earlier. RP stated she received a call stating her mom had a fall, but she was alright. It was explained to her CNA A attempted to pick her up by herself. RP stated she asked was the mechanical lift used because her mother had been using the mechanical lift since she had been at the facility since 2018. RP stated she was advised the next day her mother complained of arm pain and the NP had an x-ray done and it revealed she had a humeral fracture. RP stated she did not want her to go the hospital because she did not want her to be disoriented due to her dementia that time of the night. RP stated there was no documentation of her having any pain. RP stated the hospital advised her to send Resident #1 to another facility with her having sub-acute fractures which appeared to be a few weeks old. RP stated she did not have a fall or complain of any pain while she was out on pass with her sibling. RP stated the other time she fell was when she about a month in the facility. Resident #1 was reaching for something, and she hurt her shoulder when she fell out of her wheelchair. Her arm was placed in a sling. RP stated Resident #1 had a bedside table that tipped over on her and she had an x-ray on her toes it was just swelling. Resident #1 complained her foot was hurting in the ER and they showed a fracture on her toes. She has a shoe on her foot. RP stated it happened a couple of months ago. Record review of CNA A's employee coaching and counseling record dated 12/14/2024 revealed the fall during the transfer may have been preventable with adherence to proper facility protocol, including using assistive devices, foot ware, timely reporting to the charge nurse and asking for assistance from colleague. CNA A was placed on suspension on 12/16/2024 and terminated on 12/18/2024. Record review of the facilities investigation summary report dated 12/14/2024 revealed the ADM and ADON contact with CNA A and obtained the statement: CNA A stated it was the end of her shift and she did not see anyone in the area, so she attempted to move her from the wheelchair to the bed herself. This was unsuccessful, resulting in CNA A lowering the Resident #1 to a sitting position on the floor. CNA A requested assistance from CNA B who directed her to the LVN to report the fall requires an assessment. CNA A notified LVN C of the incident and he responded to assess Resident #1 and there were no negative findings, LVN C completed a Coaching and Counseling record for CNA A regarding improper transfer, adhering to facility protocol including using assistive devices; footwear; timely notifications. CNA A insisted she tried to pivot Resident #1, and when she was unable to complete the turn, she then lowered her to the floor and asked for help. During an interview with the ADM on 12/31/2024 at 2:13pm with the Transfer policy was requested but was not provided prior to exit. Record review of the facility CNA Job Description revised in January 2017 revealed staff were to comply with requirements of procedures for safe lifting an/or safe transfer of patients per established policies and procedures. Record review of Resident#1 x-ray dated 12/15/2024 at 8:37pm revealed the bones appear diffusely demineralized. Left humeral neck fracture with no mature callus seen. No joint dislocation. No comparison studies. During an interview with NP on 01/14/2025 revealed she was not the NP on call that weekend, and she only read the results from the x-ray. She stated Resident #1 was discharged when she came in on Monday. NP stated she does not have permissions at the hospital to collect any information regarding the resident. She stated she would attempt to get in contact with the NP that was on call. During an observation on 1/14/2025 at 5:25pm, CNA B, CNA C, CNA D, and CNA E was observed properly operating the mechanical lift with 2 residents. Record review of Skills checks on Transfers revealed that staff had been done on 12/16/2024. Record Review of in-services completed on 12/15-12/16/2024 on Mechanical Lifts, Abuse and Neglect, and timely Incident Reporting, and Prevention of Falls and Significant Injuries by Utilizing Daily Care guides revealed staff had been trained. Record review revealed that Resident #1 was discharged to the hospital on 12/15/2024 and did not return to the facility. The noncompliance was identified as PNC. The IJ began on 12/14/24 and ended on 12/16/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) for 1 (Resident #2) of 1 reviewed for pharmaceutical services. MA D left Resident #2's medications with her and walked out without observing Resident #2 taking the medications. This failure could place residents at risk for not receiving a therapeutic effect or another resident getting the medication. The findings were: Record review of Resident #2's face sheet dated 12/31/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of fracture, pain, heart disease, sleep disorder, muscle spasm, injury of head, weakness and gastroesophageal reflux disease without esophagitis (reflux). Record review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Record review of Resident #2's care plan, dated 12/31/24, revealed there was no care plan for Resident #2 to self-administer her medications. Record Review of Resident #2 medical chart on 12/31/2024 revealed Resident #2 did not have a self-administer evaluation. During an observation on 12/31/2024 at 1:43pm MA D come into the room and give Resident #2 pills and walked away without watching the resident take the medication. Resident #2 was observed asking MA D for water as MA D was leaving. During an interview with MA D on 12/31/2024 at 1:53pm revealed some residents do not want her to stay in the room with them while they take their pills. She said in those cases she would leave the pills and check back later. She said she does know she was supposed to watch the resident take the medication. She said the resident could choke on the medication if not supervised. She said she did not watch Resident #2 because she did not like her watching her take her medication. During an interview with Resident #2 on 12/31/2024 at 2:13pm revealed that MA D normally watches her take her medication before leaving the room. She said this was the first time she had walked out without watching her take the medication. During an interview with UM on 12/31/2024 at 2:15pm revealed staff who pass medication to residents were to watch and ensure the resident took the medication. She said if staff were not watching a resident take the medication a resident could have a swallowing issue that staff do not know about. She also said they could save the medication or give it to another resident. She said she was not aware that MA D had left medication with Resident #2. During an interview with the ADON on 12/31/2024 4:00pm revealed residents were to have a self-administration assessment before staff can leave medication with a resident. She said Resident #2 did not have a self-administration assessment at the time MA D left the medication with Resident #2. She said MA D was supposed to ensure that Resident #2 took the medication. She said MA D should have stayed in the room with Resident #2 until she took the medication. She said that if a resident was not able to self-administer medication and staff did not supervise it put the resident at risk of choking. She said she did not know why MA D did not stay and supervise Resident #2 taking her medication. During an interview with the ADM on 12/31/2024 at 4:17pm revealed staff who passed medication were to supervise the resident while taking the medication. She said that staff were to stay and supervise unless they were able to self-administer medication. She said for a resident to self-administer medication the facility had to do a self-administration assessment and put it in the resident's care plan. She said if staff did not monitor residents who did not have a self-administration assessment the resident could choke. She said MA D said the resident did not want to be watched when taking medication. She also told MA D that the residents must be supervised unless they are allowed to self-administer medication. During an interview on 12/31/2024 at 2:09pm.with ADM the Medication administration policy was requested but was not received prior to exit.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility on 08/22/24. She was found less than two hours later approximately one mile away at a gas station on a busy street. She had a fall which resulted in a swollen face and a cheek abrasion. This noncompliance was identified as PNC IJ. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for, falls, injuries, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cognitive impairment, unspecified dementia, history of fractures, muscle spasms, and shortness of breath. Review of Resident #1's admission MDS assessment, dated 05/06/24, reflected a BIMS of 3, indicating a severe cognitive impairment. Section D (Mood) reflected the behavior of wandering had not been exhibited. Review of Resident #1's quarterly care plan, dated 05/24/24, reflected she was at risk for falls related to impaired mobility with an intervention of keeping areas free of obstructions to reduce the risk of falls or injury. It further reflected she had the potential risk for elopement with an intervention of assessing her for elopement on admission, readmission, quarterly and with any significant changes. Review of Resident #1's quarterly Elopement Risk Assessment, dated 08/09/24, reflected she was a moderate risk for elopement due to her cognitive impairment and wandering aimlessly. Review of Resident #1's quarterly Fall Risk Assessment, dated 08/22/24, reflected she was a high risk for falls. Review of Resident #1's progress notes, dated 08/22/24 a 6:56 PM and documented by RN A, reflected the following: [Resident #1] was in her room at 3:35 PM evening meds was administered. At 3:45-4:30 [Resident #1] was noted in activity room with other residents. At 5:25 PM while passing dinner tray, [Resident #1] was not in her room this nurse checked the bathroom and [Resident #1] was not in the bathroom. CNA working in 300 hall stated that did not see [Resident #1], roommate stated that ([Resident #1] took her parse [sic] and said I will be back shortly). This nurse alerted all staff at the station of [Resident #1] not in the room, staff start searching for resident in all the rooms and bathrooms, outside the building and around, as well as the next building (facility name) and staff driving out on the streets looking for her, second nurse's station also were looking for her, family called and notified . DON notified at 5:35 PM and 6:10 PM when family arrived at the facility, [Resident #1] was found the roadside on (road name) near the (gas station), by a passerby whom the (family member) reported called family member and told them that [Resident #1] is on the road side and has fallen. Then brought [Resident #1] to the facility . head to toe assessment completed, abrasion to left check [sic] with some dried blood, face swollen, resident was agitated, confused, and combative . EMS was called at 6:15 PM per family request . Observations made on 08/24/24 from 10:45 AM - 10:58 AM revealed the MRD testing all eight exit doors throughout the facility to ensure the alarms worked. Each door sounded appropriately at the door and at the nurses' station. The MRD utilized the door code to turn off the alarm at each door. Observation of facility video footage, dated 08/22/24 at 5:12 PM, revealed Resident #1 ambulating independently out the front door behind a family member. During an interview on 08/24/24 at 11:01 AM, LVN F stated he was the nurse weekend supervisor. He stated he had been briefed regarding the incident with Resident #1 and in-serviced by the DON . He stated Resident #1 had a history of ambulating around the building but never saw her attempt to leave or exit-seek. He stated the facility does not have any residents that he has witnessed exhibiting any exit-seeking behaviors. During an interview on 08/24/24 at 11:55 AM, the DON stated he was notified immediately when Resident #1 could not be found. He stated he headed to the facility and advised his staff to keep searching. He stated she was found less than two hours later near a gas station . He stated she had fallen onto her knees and two pedestrians went to assist her and saw her phone in her purse and contacted the last person she had contacted (FM D). He stated she was sent to the hospital per family request and was assessed with no further injury. He stated she was still in the hospital while the family decided on which facility to send her to that had a locked unit. He stated she had no prior history of attempting to leave or any exit-seeking behaviors. He stated they initially thought she may have exited through a side emergency exit door, but they were all tested and in working condition. He stated after reviewing video footage they were able to observe her walking out the front door behind a family member . He stated all staff were in-serviced before their shifts. During an interview on 08/24/24 at 1:42 PM, the REC stated on 08/22/24 she was in the front area and had clocked in around 3:30 PM. She stated she was doing her normal work duties and did not witness Resident #1 by the front desk or leaving the facility. She stated she went to clock out around 5:45 PM and an aide asked if she had seen Resident #1. She stated all staff began looking for her. She stated she had a high-elopement risk binder at her desk and knew not to let any resident leave unless she knew they were allowed to sign out on pass. She stated that same day staff were in-serviced like crazy. She stated they were in-serviced on abuse and neglect, the elopement process, and exit door codes. She stated the door codes of the emergency doors (excluding facility entrance/exit door) should never be given out to family or residents. During an interview on 08/24/24 at 1:53 PM, LVN B stated she had been in-serviced before her shift on elopement, rounding on residents every two hours, answering call lights in a timely manner, and abuse and neglect. She stated if a resident was missing, she would notify the DON and ADM immediately. She stated the emergency exit side doors were not to be used unless there was an emergency. She stated she would never give the exit code out to anybody. She stated there were binders with high-risk elopement residents at the REC's desk as well as at each nurse's station. During an interview on 08/24/24 at 2:34 PM, LVN C stated she was not working the day Resident #1 left the facility. She stated Resident #1 sometimes talked about wanting to go to the bank but never exhibited any exit-seeking behaviors. She stated she had been in-serviced before her shift on abuse and neglect, elopement, and door codes. She stated if a resident could not be found, the DON and ADM needed to be notified immediately after she ensured all staff started searching. She stated she would call the REC to see if any residents had left the facility. She stated it was important to lay eyes on all residents every two hours to ensure all are accounted for. She stated the exit doors are not to be used unless there was an emergency. During an interview on 08/24/24 at 2:59 PM, RN A stated Resident #1 did not have a history of trying to leave the facility. She stated she never even talked about wanting to leave. She stated on 08/22/24, she last saw her around 3:45 PM when she gave her medication. She stated when she took her dinner tray to her room, she noticed she was not in there. She stated she immediately started searching for and asking staff members. She stated the CNA told her she had seen her in the activity room around 4:45 PM. She stated she went to the activity room but she was not in there. She stated she searched all rooms on her hallway, and contacted her family to ensure she was not with them. She stated at that time, all staff started searching the facility, outside, and the courtyard. She stated she contacted the DON and ADM. She stated shortly after, Resident #1's FM D called her and informed her that a passer-by found her by the gas station down the street and dialed the last person that had been called on Resident #1's phone (FM D). She stated she knew none of the exit door alarms had gone off and she knew she had not left through the side doors. She stated all staff were immediately in-serviced by the DON on elopement, who to notify, when you hear an alarm go off to do a head count your residents immediately, and knowing where they were at all times. During an interview on 08/24/24 at 3:11 PM, CNA E stated she was working the day Resident #1 left but was not working her hall. She stated she was familiar with Resident #1 and had never seen her attempt to exit the facility. She stated when it was noticed Resident #1 was missing on 08/22/24, everybody stopped what they were doing and started looking in all of the rooms, bathrooms and outside. She stated in-services conducted by the DON started that evening on elopement and exit doors. She stated it was important to check on the residents constantly and the residents that were a high-risk of elopement (per elopement bind er) should be checked on more often. She stated the only door that should be used to enter/exit the facility was the front door. Review of an in-service entitled Building Entrances and Emergency Exits, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced on the following: Visitors and staff should be only utilizing the front entrance. Side doors are for emergency only and no persons should be coming in or going out of these doors. Review of an in-service entitled Elopement, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced elopement procedures. Review of an in-service entitled Abuse and Neglect, dated 08/22/24 - 08/23/24 and conducted by the DON, reflected all staff were in-serviced abuse and neglect. Review of an in-service confirmations, dated 08/22/24 - 08/23/24, reflected all staff signed an attestation form that they were in-serviced on the following: Elopement and missing persons, shift change walking rounds, Q2 hours body count and sign offs, procedure for missing/elopement patients - q 15 shift, how to identify change in condition, i.e. exit seeking and who to report it to. Review of an audit conducted by the DON, on 08/22/24, reflected all residents had a new elopement risk assessment conducted and no residents were deemed as a high risk. Review of the facility's Elopements policy, revised December of 2007, reflected the following: Staff shall investigate and report all cases of missing residents. 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. This noncompliance was identified as PNC. The deficient practice began on 08/22/24 and ended on 08/23/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences by not ensuring the resident call system was accessible to 3 (Resident #1, Resident #2, and Resident #3) of 6 residents reviewed for call systems. - Resident call system was not accessible for Resident #1, Resident #2, and Resident #3. This failure could endanger the health or safety of the resident or other residents if they are not able to call for assistance when needed. Findings include: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of aftercare following surgery for malignant neoplasm of pancreas (pancreatic cancer), diabetes mellitus type 2, hypertension, pain, and diarrhea. Review of the Admission MDS assessment for Resident #1 dated 05/05/24 did not reflect a BIMS score. Section GG reflected Resident #1 needed partial assistance from another person to complete activities, required the aide of a walker and a wheelchair, and required maximal assistance for toileting, showering/bathing, and dressing upper and lower body. Review of the Care Plan for Resident #1 dated 05/06/24 reflected the following: Resident #1 was at risk for falls related to impaired mobility, to place call light/bell within easy reach, and to respond promptly to calls for assist to the toilet. Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of deep vein thrombosis of left lower extremity (blood clotting), aftercare following surgery of left lower extremity/circulatory system, anemia, depression, hypothyroidism (underactive thyroid), hypertension (high blood pressure), and pain. Review of the Admission MDS assessment for Resident #2 dated 5/01/24 reflected a BIMS Score of 99 which reflected the resident was unable to complete the interview. Review of the Care Plan for Resident #2 dated 5/06/24 reflected: Resident #2 was at risk for falls related to impaired mobility and to place call light/bell within easy reach and to respond promptly to calls for assist to the toilet. Resident #2 has a self-care deficit and required extensive assistance with bed mobility, bathing, hygiene, dressing and grooming related to weakness. Resident #2's transfer status required gait belt and assistance of one person and set-up assistance with meals. Review of the undated face sheet for Resident #3 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2, muscle weakness, cognitive communication deficit, constipation, altered mental status, depression, peripheral vascular disease (narrowing, blockage or spasms in a blood vessel), hypertension, and Alzheimer's disease. Review of the Admission MDS assessment for Resident #3 dated 04/28/24 reflected a BIMS Score of 14 which reflected mildly impaired cognition, and use of a walker and a wheelchair. Resident #3 required partial to moderate assistance with bed mobility, bathing, hygiene, dressing and grooming. Review of the Care Plan for Resident #3 dated 5/06/24 reflected: Resident #3 was at risk for falls related to impaired mobility and to place call light/bell within easy reach and to respond promptly to calls for assist to the toilet. Observation on 5/06/24 at 1:00 PM revealed Resident #1's call light was on the floor by the head of the bed. Interview on 5/06/24 at 1:00 PM with Resident #1 revealed he had an issue with the call button not being answered and was having frequent diarrhea for the past two months following abdominal surgery. Resident #1 stated he would press the call button for help but nobody would come, or they would come in and tell him they would be right back and never come back. Resident #1 stated his wife could help him by picking up the call button when she was visiting, and if he was alone he would not be able to get help. Resident #1 stated he thought the facility was short staffed and had waited one hour for 4-5 times during past week to get cleaned up from having diarrhea. Observation on 5/06/24 at 1:14 PM of revealed Resident #2 was sitting up in wheelchair in her room with lunch tray on bedside table. Resident #2 stated she had no concerns with her care. Resident #2's call button was observed on the floor near the head of the bed. Resident #2 stated she was soon going to need to get up. Observation on 5/06/24 at 1:16 PM revealed CMA A had gone into Resident #2's room momentarily to check on her and then came out of the room and back to the med cart. Observation on 5/06/24 at 1:19 PM revealed Resident #2's call light remained on the floor in the same spot as first observation at 1:14 PM. Observation on 5/06/24 at 1:25 PM revealed Resident #3 sitting up in his wheelchair and his lunch tray on bedside table. Resident #3 stated he did not speak much English. Resident #3's call light was observed on the floor near the head of the bed. Interview on 5/06/24 at 2:02 PM with CMA A revealed she had worked at facility for five to six years. CMA A stated she will ask residents if they want their light left on or off, door opened or closed, and if they need anything else. CMA A stated, the call light is usually around the bed, and if it were on the ground, she would pick it up. CMA A further stated, I don't know why I did not pick up Resident #2's call light when I went into her room and we are supposed to make sure all residents have their call light nearby. Interview on 5/06/24 at 2:05 PM with LVN A revealed she checked the overall condition of how a resident room looks, and for any equipment issues. LVN A stated she also looked at call lights, and the call light was usually pinned to bed or pinned to the resident. LVN A stated if the call light was found on the floor and someone goes in to help them, they should pick it up. Interview on 5/06 24 at 3:22 PM with the DON revealed the importance of call light in reach when residents were going to bathroom, difficulty breathing, if they have fallen, or any type of need. The DON revealed his expectation was for all staff members to place all residents call light within reach while they are in bed, or up in chair. The DON further stated if the resident did not have their call light within reach, they could have a fall, have an emergency, need to go to the bathroom, or become soiled. Review of Policy and Procedure for Answering the Call Light dated October 2010 reflected, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident and to answer the resident's call as soon as possible.

Based on observation, interview and record review the facility failed to ensure the residents' had the right to a safe, clean, comfortable and homelike environment, which included but not limited to receiving treatment and supports for daily living safety for 6 residents (Residents #9, #29, #40, #57, #61 and #68) of 20 residents reviewed for resident rights. The facility failed to ensure resident room water temperature was maintained at a comfortable warm temperature which was at least 100 degrees F. This failure could place residents at risk for living in an uncomfortable, and unhomelike environment which could cause a diminished quality of life. The findings include: 1. Record review of Resident #9's clinical record reflected Resident #9 was [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included Parkinson's (disorder of central nervous system affects movement)and muscle weakness. Record review of Resident #9's MDS quarterly assessment, completed 2/16/24, documented a BIMS score of 12, which indicated the resident was moderately impaired. Resident #9 required set-up and clean up assistance needed for shower and bathing self and personal hygiene. Record review of Resident #9's care plan completed 7/25/23 reflected, Problem: Self-care deficit - Extensive assistance x1-2 required with bed mobility, bathing, hygiene, dressing R/T debility. Goal: Will be odor free, dressed and out of bed daily over the next 90 day. Status: Active (Current). Intervention: Bathe/shower resident. 2. Record review of Resident #21's clinical record reflected Resident #21 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included schizoaffective disorder (mental health condition including schizophrenia and mood disorder), major depressive disorder( persistent depression) and muscle weakness. Record review of Resident #21's MDS quarterly assessment, completed 3/13/24, documented a BIMS score of 14, which indicated the resident was cognitively intact. Resident #21 required set-up and clean up assistance needed for shower and bathing self and personal hygiene. Record review of Resident #21's care plan, completed 3/07/24, reflected, Problem: set-up and clean up assistance needed for shower and bathing self and personal hygiene. Goal: will maintain a sense of dignity by being clean, dry, odor free and well-groomed over 90 days. Intervention: assist with showers three times a week and as needed. 3. Record review of Resident #29's clinical record reflected Resident #29 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #29 had diagnoses which included heart failure and morbid obesity (overweight). Record review of Resident #29's MDS quarterly assessment, completed 2/19/24, documented a BIMS score of 14, which indicated the resident was cognitively intact. Resident #29 required set-up and clean up assistance needed for shower and bathing self and personal hygiene. Record review of Resident #29's care plan, completed 2/22/24, reflected, Problem: Self-care deficit - Extensive to total assistance x1-2 required with bed mobility, bathing, hygiene, dressing and grooming, wheelchair mobility related to debility Goal: Will be odor free, dressed and out of bed daily over the next 90 day. Intervention: Bathe/shower resident. Hoyer Lift x2 person with transfers. 4. Record review of Resident #57's clinical record reflected Resident #57 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included Parkinsonism (disorder of central nervous system affecting movement), blindness in one eye and muscle weakness. Record review of Resident #57's MDS quarterly assessment, completed 2/9/24, documented a BIMS score of 11, which indicated the resident had moderately impaired cognition. Resident #57 required set-up and clean up assistance needed for shower and bathing self and personal hygiene. Record review of Resident #57's care plan, completed 11/23/23, reflected, Problem: set-up and clean up assistance needed for shower and bathing self and personal hygiene. Goal: will maintain a sense of dignity by being clean, dry, odor free and well-groomed over 90 days. Intervention: assist with showers three times a week and as needed. 5. Record review of Resident #61's clinical record reflected Resident #61 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included mild cognitive impairment and muscle weakness. Record review of Resident #61's MDS quarterly assessment, completed 1/10/24, documented a BIMS score of 13, which indicated the resident was cognitively intact. Resident #61 required limited to extensive assistance required for shower and bathing self and personal hygiene. Record review of Resident #61's care plan, completed 2/14/24, reflected, Problem: limited to extensive assistance required for shower and bathing self and personal hygiene. Goal: will maintain a sense of dignity by being clean, dry, odor free and well-groomed over 90 days. Intervention: assist with showers three times a week and as needed. 6. Record review of Resident #68's clinical record reflected Resident #68 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had diagnoses which included delusional disorder (unable to determine real from imagined), rheumatoid arthritis ( chronic inflammation of small joints) and muscle weakness. Record review of Resident #68's MDS quarterly assessment, completed 2/8/24, documented a BIMS score of 14, which indicated the resident was cognitively intact. Resident #68 was set-up to limited assistance needed for shower and bathing self and personal hygiene. Record review of Resident #68's care plan, completed 3/12/24, reflected, Problem: set-up to limited assistance needed for shower and bathing self and personal hygiene. Goal: will maintain a sense of dignity by being clean, dry, odor free and well-groomed over 90 days. Intervention: assist with showers three times a week and as needed. Observations on 03/12/24 at 10:00 AM, accompanied by the Maintenance Supervisor, revealed hand sinks in resident rooms had temperatures below 100 degrees F. Room for Resident # 09 76.7 degrees F Room for Resident # 40 83.9 degrees F Room for Resident # 57 90.4 degrees F Room for Resident # 61 84.0 degrees F Room for Resident # 68 85.9 degrees F During an interview on 03/12/2024 at 10:00 AM with Resident #61 revealed the resident voiced he did not have warm or hot water when he used his sink and shower. Resident #61 stated since the freeze in January, he was without hot water for a while. Resident #61 stated some days the water was too cold for showers. Resident #61 stated he complained to staff and refused baths due to water being too cold. During an interview on 03/12/2024 at 11:00 AM, Resident #68 stated water was too cold to shower or wash her face. Resident #68 stated she had an appointment with the doctor but had to go without a shower because it was too cold and she felt angry and ashamed. During an interview on 03/12/2024 at 11:15 AM, Resident #57 stated the water was too cold for showers. Resident #57 stated the aides had to let the water run a long time before showers and there were times the water did not heat up. During an interview and observation on 03/13/24 at 10:36 AM revealed the water temperature in Resident #9's room was taken with a thermometer and noted to be 89.2 degrees Fahrenheit after running the shower for 7 minutes. Resident #9 said the water in his bathroom was cold at times and due to that he had to take a cold shower sometimes. Resident #9 said he would get upset about having to take a shower with cold water, as it was uncomfortable. Resident #9 said he reported it to someone and they said they were working on it, but they never did get it fixed. During an observation and interview on 03/13/24 at 11:47 AM revealed the water in resident room [ROOM NUMBER] was left on for 12 minutes, while the DON was present, the water temperature was 86.0 degrees Fahrenheit. The DON asked what the temperature should be. Interview on 03/13/2024 at 11:00 AM with the Maintenance Supervisor revealed the facility had complaints of the water being cold. The Maintenance Supervisor stated in January there was a winter freeze and the pump went out so the facility lost hot water in half the building. Since then, the water took longer to get warm on the 300 hall. The Maintenance Supervisor stated the facility only had 2 water heaters for 300 & 400 hall. The other reason the water was cold in the mornings was because the pipes were in the attic, so when the weather was cold outside, it affected the water temperature. During an interview on 03/13/24 at 11:52 AM, Resident #29 said the water in her shower was cold so she would not take a shower. Resident #29 said last week the was cold as well but she took her shower any ways. Resident #29 said the last time she took a shower was Saturday 03/09/2024 and today was Wednesday 03/13/2024 and she had not showered due to the water being cold. Resident #29 said they would let the water run for a while and it would still not get hot. Resident #29 said not taking a shower made her feel dirty and uncomfortable. Resident #29 said she was not sure if the Administrator or maintenance knew about the water being cold. During an interview on 03/13/24 at 12:00 PM, Resident #21 stated there was no hot water for morning showers. Resident #21 stated it was too cold at times and she had to allow the water to run for 20 minutes or more to heat up. Resident #21 stated there were times it did not get hot enough for a comfortable shower. During an interview on 03/13/24 at 12:20 PM, CNA A said she showered residents at the facility. CNA A said some of the residents complained the water was cold. CNA A said the water would come out kind of cold so they would have to let the water run for about 45 minutes and up to an hour before it got hot enough to shower the residents. CNA A said she had not had to stop a shower due to the water getting cold while showering a resident. CNA A said some of the resident's complained the water felt lukewarm. CNA A said the Maintenance Supervisor was aware and he told them he was working on the water temperature adjustments. During an interview on 03/14/24 at 09:58 AM, CNA H said last week she showered some residents and the water took a long time to get hot. CNA H said she usually had to run the water for about 30 minutes before it got warm enough to shower the residents. CNA H said it would take a long time to get the residents showered because she had to first run the hot water for a while before she got the resident into the shower. CNA H said each resident had their own shower in their room. CNA H said during the showers some of the residents would say to turn the water warmer but she would tell them that was as hot as it was going to get. CNA H said she told the maintenance staff before but they said they were working on it or had already worked on it. During an interview on 03/14/24 at 12:00 PM, the Administrator said during a freeze the pipes busted the filters on the water heaters and hot water would not get to some rooms. The Administrator said for whatever reason the water took a while to get hot and was not sure what was going on. The Administrator said they told staff to report if the water was not hot. The Administrator said she understood about the water temperatures and the residents not wanting to shower. The Administrator said they were still working on the issue and they had the plant operations manager checking it out. Record review of the facility's policy titled; Resident Rights revised December 2016 reflected in part: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to a dignified existence, the right to voice grievances to the facility, the right to have the facility respond to grievances. Record review of the facility's policy titled; Environmental Temperature dated January 2016 stated in part all water supplied to patient use areas must be maintained between 100-110 degrees F.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and that the resident environment remained as free of accident hazards as was possible for one of five residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 who was identified as being at moderate risk for elopement was adequately supervised. The resident was identified as missing on 1/6/23. He was found at least seven (7) hours later on 1/7/23, in an internal courtyard of the facility across from his room. An IJ was identified on 01/27/23. The IJ template was provided to the facility on [DATE] at 05:07 PM. While the IJ was removed on 01/30/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility continued to monitor to ensure assessments for elopement were accurate for all residents. This failure placed residents at risk of injury due to not being supervised and placed at risk of accidents/hazards. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia associated with Parkinson's and neurological disorder with Lewy bodies (protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement- can cause visual hallucinations and changes in alertness and attention). Review of the admission MDS for Resident #1 dated 01/19/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. It reflected that wandering behavior had occurred one-three days of the lookback period. It reflected Resident #1 required the limited assistance of one person for locomotion. Review of the Elopement Risk section of the Nursing Admission Assessment for Resident #1 dated 12/29/22 reflected he was a Moderate Risk, meaning 1) he was cognitively impaired and 2) he ambulated or propelled self. It also reflected Resident #1 went outdoors on occasion but did not try to leave the grounds. Review of the care plan for Resident #1 dated 01/27/23 reflected the following: Potential for elopement as evidenced by going out to room across hall and exiting into patio. Exit seeking. Maintaining the least restrictive environment while providing for (Resident #1) safety for 90 days. Frequent monitoring. All staff. Photo in MAR and Elopement risk book. All staff to be made aware of (Resident #1) risk status, via staff sign-in book and verbal reports qs and prn. If possible, have family or volunteers visit on a regular basis. Keep MD and family informed. Reorient/Redirect prn. Reassess as needed. Review of nursing progress notes for Resident #1 reflected the following: 01/06/23 at 08:23 PM by LVN A Rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury) resident AAO times 2 (oriented to person and place but not time and situation), forgetful with short term memory. Continually reminding resident to stay seated or to use the call light. Resident unable to recall any education. Bed in lowest position. Continued rounds on resident the shift for safety. Call light within reach for resident at all times; does not use it. 01/07/23 at 05:55 AM by LVN B While doing rounds patient not in the room. This nurse called and spoke to patient (family member). (Family member) stated the patient not with (family member). Management notified. Local police notified. 01/07/23 at 07:27 AM by LVN B Resident on patio in opposite room, laying in bushes on his back, staff and management present. Resident alert and oriented to self but confused about where he is and why. Staff and local police assisted patient to wheelchair, resident, cooperative, and telling jokes. (Family member) present. Resident has no visible, bruising or swelling noted. 01/07/23 at 08:48 AM by LVN B Spoke with on-call NP to notify her of resident's fall. Stat labs ordered for CBC and BMP. No UA order due to resident just getting off ABT from UTI. Order has been placed. 01/07/23 at 06:16 PM by DON Late entry: this writer notified that resident could not be located during morning med pass. When arrived at the facility, this writer spoke with Administrator. This writer searched the empty room across the hall and discovered resident around 6:30 AM on the patio laying in the bushes. This writer and a ADON notified police and administrator. Police assisted this writer assess and get resident out of the bushes. Resident had no broken skin or new bruises and had redness from the brush. Resident was pleasantly confused A&O times two making jokes with the officers and staff. This has been resident baseline. Complete head to toe and clothes changed. (family member) arrived and spoke with her and advised her that it will be best to have resident assessed in the ER as a precaution. (Family member) was hesitant but agreed. Paramedics arrived and assessed VS WLN and spoke with (family member) and stated that they did not feel he needed to go, but it was her final decision. (Family member) stated that she really did not want him to go to the ER and wanted facility to manage his care. On-call NP notified and labs ordered and resident placed on 15 minute checks. (Family member) is OK with plan and resident is resting in bed and (family member) at bedside. Review of the provider investigation report dated 01/10/23 reflected the following: Other pertinent history: has history of confusion, no wandering per family. Description of the allegation: Missing resident Description of assessment: Head to toes assessment completed by DON. No injuries noted at this time. Investigation summary: On 1/7/23 at approximately 5 AM, this writer received a call that patient one was not in room. This writer notified nurse to call family and have all staff begin to search the interior and exterior of the building. This writer made it to the facility at approximately 528 to begin search for the patient. We confirmed with family that patient was not with them or other family members. Staff continued search for patient and this writer at approximately 5:45 AM called 911 to report a missing patient. The police arrived at facility and asked for floor plan of facility and received description of patient as well as picture of patient. The DON continued to search for the patient, and at approximately 6:45 AM found patient on the patio in a room adjacent to his. Patient was lying in bushes on his back. Patient was pleasantly confused and did not seem to have injuries noted. The DON took the patient back to his room and did a full body assessment. The Patient had minimal scratching on his back and some redness on his back, which was all resolved by the end of the assessment. The Patient did not note any pain at this time. We did call EMS as precaution, but they did not see a needed for patient to go to ER and stated we can run labs and assess at facilityThe Ffamily did sign a waiver to not transport to EMS. Facility NP requested stat labs. Labs completed with no intervention necessary. UA was not completed as patient had just finished a round of antibiotics. Patient was put on Q15 minute checks. Patient did not exit seek at all during observation. He has a high fall risk so he does require frequent monitoring and fall intervention. Patient was moved to room that does not have a patio room adjacent to it to prevent patient from entering vacant room to exit to enclosed patio. Patient has not had any behaviors of exit seeking prior or before incident. Review of facility NP exam dated 12/30/22 reflected the following: HPI limited D/T dementia diagnosis. Information supplemented by hospital records and staff report. Patient is AAO to self, calm, property. He is up in recliner, eating lunch and denies N/V/C/D, dyspnea, and pain. He is ambulatory, incontinent of B/B and lives at home with his family member. He is a retired police officer. VSS on RA, no concerns reported by staff. Psychiatric: insight: poor insight. Mental status: normal mood, affect, and attentiveness and active and alert. Thought process: ordered. Orientation: oriented to person. Memory: recent memory, abnormal, and remote, memory abnormal. Speech normal speech, and comprehension. Assessment/plan: Dementia associated with Parkinson's disease- per records, patient's (family member) reported he no longer takes carbidopa levodopa. No tremors noted on exam, patient alert and oriented to self with some remote memory intact. Review of an Elopement Risk Assessment for Resident #1 dated 01/07/23 reflected that Resident #1 was an Imminent Risk in that 1) he ambulated or propelled himself and/or wandered and had intentionally or unintentionally attempted to leave the community. Review of facility NP exam dated 01/09/23 reflected the following: Medications not reviewed (last reviewed 12/31/2022) Patient is new to me. Chart reviewed. Patient seen today for SNF management of multiple medical problems. Over the weekend, patient reportedly fell in a bush in the courtyard. Family requested labs be drawn. CBC and BMP was ordered. WBC elevated at 12.1. Patient seen today, awake, alert, resting in recliner. No acute distress noted. Patient denies chest pain, SOB, N/V/D/C, urinary urgency, or frequency. Per nursing, no concerns. Lungs clear on exam. No suprapubic tenderness noted. Patient denies concerns. Physical exam Psychiatric: insight: poor insight. Mental status: normal mood, affect, and attentiveness and not active and alert. Thought process: ordered. Orientation oriented to person. Memory: abnormal and remote, memory abnormal. Speech normal speech, and comprehension. Assessment/plan: Dementia associated with Parkinson's disease- per records, patient's (family member) reported he no longer takes carbidopa levodopa. No tremors noted on exam, patient alert and oriented to self with some remote memory intact. Poor concentration in for short term memory. Review of Psychosocial Well-Being Assessment for Resident #1 dated 01/13/23 reflected the following: Current psychosocial/relationship problems, consistent with patient's long-standing lifestyle, or is this relatively new for the patient? Onset of dementia has become hard for a (family member) to be able to care for resident. Referral to (psych services provider). An attempt to interview LVN A by telephone was made on 01/27/23 at 12:56 PM. A voicemail message was left. During observation and an interview on 01/27/23 at 11:35 AM, Resident #1 was sitting up in his wheelchair, dressed, groomed, and clean with no visible injuries and a tray from his meal in front of him Resident #1 stated he did not remember spending a night outside and had no complaints. Resident #1 stated his sister also lived there and would not let anything happen to him. During an interview on 01/27/23 at 01:00 PM, CNA C stated she worked the overnight shift the night Resident #1 went missing. CNA C stated she came in on her shift at 10:30 PM, clocked in, and immediately did a walk through. CNA C stated she always worked on the same hall and Resident #1 lived on that hall in the first room. CNA C stated he was not in his room, but she continued to do her walk through. CNA C stated when she was done with her rounds, she went to the nurses, who were giving each other shift report. CNA C stated LVN A was going home and giving report, and LVN B was coming on shift and receiving report. CNA C stated LVN A told LVN B and her Resident #1 was not there, and CNA C thought she remembered LVN A saying Resident #1 was not there. CNA C stated she figured LVN A would explain to LVN B why Resident #1 was not there, and she went about her duties. CNA C stated she did not ask anything else at that time. CNA C stated she was supposed to check each of her residents every two hours regularly. CNA C stated she did not conduct room checks on Resident #1 that night, because she thought Resident #1 was not in the building. CNA C stated they finally took notice that Resident #1 should have been there when LVN B was going around to give medication at around 05:00 AM and Resident #1 was not there. CNA C stated LVN B called the family to verify he did not leave with them, and from there they started looking for him. CNA C stated everyone in the building stopped and looked everywhere- every room, every closet, and walked outside the perimeter. CNA C stated their administrator was the manager on call, and the administrator made sure they did the proper missing resident protocol. CNA C stated the proper protocol was to look everywhere, notify the police, notify the family, and to keep looking. CNA C stated her shift ended at 06:00 AM, and she only stayed long enough to give a statement for the police and went home. CNA C stated she did not hear any updates until she came back to work and heard that he was found in their courtyard inside a bush. CNA C stated they had made changes, and she and her coworkers had been in-serviced on the changes. CNA C stated now they immediately had to go check all the resident rooms, share report with the nurses, and the nurses did their own room checks. CNA C stated they were still doing the checks each fifteen minutes on Resident #1, but they were not documenting it. CNA C stated she was in-serviced was about safety and awareness of protocols for elopement. CNA C stated there were no other residents she worked with who were similarly at risk. CNA C stated Resident #1 was generally very confused, and at night, he would always be up and confused about the time of day. CNA C stated they just gave Resident #1 reminders that it was nighttime. CNA C stated she would usually catch Resident #1 standing up by his restroom, and he thought he was about to go to work, or his family member was coming for him. CNA C stated Resident #1 did not have a door to the patio in his room, but there was one in the empty room across the hall. CNA C stated she assumed that was how he got out. During an interview on 01/27/23 at 02:03 PM, the DON stated she received a call at 05:00 AM on 01/07/23 from the overnight nurse. The DON stated LVN B told her she had thought Resident #1 was signed out on pass but when she went to give him his medication, he was not marked as gone in the electronic charting system. The DON stated LVN B told her she had gotten from shift change report that Resident #1 was out on pass. The DON stated she understood LVN B called the ADM, called the family, and when no one knew where Resident #1, the alarm went out. The DON stated they got conflicting stories from LVN A and LVN B. The DON stated LVN A said she had seen him sitting in his chair throughout the evening, and the CNAs on the overnight shift both told the DON LVN A had said Resident #1 was out on pass. The DON stated the police were at the facility, and all the staff searched for him. The DON stated she lived an hour away, and when she arrived at the facility, she and the ADON searched together. The DON stated the family told her Resident #1 could not get far. The DON stated they searched the neighborhood in their cars. The DON stated she was standing outside his room looking around, thinking he could not get far and she had seen him use his wheelchair as a walker. The DON stated she noticed the vacant room across the hall, and she saw the bed in that room was a little messed up. The DON stated she asked her staff if they had checked the courtyard, and they told her they had been out there with flashlights, calling Resident #1's name. The DON stated she decided to go out the patio door in the room across from his, and Resident #1 was right there laying in some bushes. The DON stated Resident #1 woke up immediately, looked at her and said Hi! The DON stated Resident #1's wheelchair was sitting on the patio with some of the patio furniture stacked on it. The DON stated they did an assessment, brought the police, and got Resident #1 in the wheelchair. The DON stated Resident #1 was just talking and laughing and being his usual self. The DON stated they did a full assessment without Resident #1's clothing, and he had bright red marks where the bushes brushed against him, but they were gone by the time the assessment was over. The DON stated they had a hard time convincing the family to send him to the ER, but they convinced the family to let them call 911. The DON stated the EMTs arrived, assessed him, and decided not to take him to the ER. The DON stated the NP ordered lab work minus a urinalysis, because Resident #1 had just finished antibiotics for a UTI. The DON stated after the incident, they did not do an elopement assessment on all the residents in the facility but they did do one on the two they knew had a risk of elopement. The DON stated it was very hard to prevent elopement for those residents, and they basically tried to redirect the ones who were a risk. The DON stated they put Resident #1 onto every-15-minute watches. The DON stated there was no wander guard system at the facility, and they were not entirely equipped for residents who wandered or exit-sought. The DON stated they moved Resident #1 into a room where he no longer had access to any patio doors. The DON stated they also put together a system of walking rounds during which both the off-going and oncoming nurses on every hall did full walking rounds together and both put eyes on every resident before shift change. The DON stated the CNAs were still checking on residents every two hours, at least. The DON stated she had told the CNAs they needed to round on the residents with elopement risk more frequently, but there was no formalized system in place for that. The DON stated the staff knew if a resident was out on pass by marking it in the computer. The DON stated if the nurse who had worked the overnight shift the night Resident #1 slept on the porch had checked the computer system, she would have known Resident #1 was not on pass, and they would have found him sooner. The DON stated LVN B had just assumed, and assuming got them into the situation where Resident #1 could have been seriously harmed. The DON stated the patio doors were the same and still opened out into the courtyard without locks. The DON stated there was a book at each nurse's station and the front of the building that contained information about the residents with a risk of elopement. The DON stated they had a QAPI meeting about the situation, but she was unable to attend. The DON stated there was a Performance Improvement Plan in place that came from the QAPI meeting. During an interview on 01/27/23 at 2:39 PM, LVN B stated she had worked the night shift on 01/06/23 when Resident #1 went missing. LVN B stated her recollection was she had gotten shift report from the off-going nurse, went down the hall for something, and when she came back and asked why Resident #1 was gone, the off-going nurse had already left. LVN B stated she asked CNA C if there was someone living in Resident #1's room, and CNA C told her he had left with his family. LVN B stated at that point, she didn't think anything about it. LVN B stated later in the shift, when she was passing medications, she looked on the computer and Resident #1's chart did say Leave Of Absence or Resident #1 was out on pass. LVN B stated she asked CNA C again at that point if she was sure LVN A had said Resident #1 was gone. LVN B stated she tried to call LVN A who texted after a long while that Resident #1 had not left that she knew of. LVN B stated at that point she started alerting the staff and looking for Resident #1. LVN B stated LVN A was very fast during the shift change report and did not say anything at all about Resident #1. When asked if a CNA approached and asked about Resident #1 while they were sharing shift report, LVN B stated she could not remember. LVN B stated when she returned to work the next night, the only change was a 15-minute check on Resident #1, which was only for that day. LVN B stated she had never seen any resident wander out of the patio door. LVN B stated she had one other resident with wandering or exit-seeking behaviors, and it was Resident #2. When asked what she did to ensure residents were safe from wandering, LVN B stated when she workeds she checkeds at night anywhere from every 30 minutes to an hour. LVN B stated she put eyes on every other resident at shift change. During an interview on 01/27/23 at 3:45 PM, the ADM stated she got a call at 05:00 AM asking if she knew anything about Resident #1 leaving or going out on pass, but she did not. The ADM stated she told the staff to call Resident #1's family and said she was on her way to the facility. The ADM stated she got to the facility in 15 minutes. The ADM stated when she learned from the family Resident #1 was not with them, she knew he was somewhere at the facility. The ADM stated no alarms had gone off at the facility, which is what would have happened if anyone had gone out any of the exit doors. The ADM stated they searched the inside and outside of the facility and then called 911. The ADM stated she was doing her investigation after Resident #1 was found, and CNA C told her the LVN A had said Resident #1 left. The ADM stated LVN B told her that CNA C said he had left but that she did not remember hearing it directly from LVN A. The ADM stated LVN A did not say when she last saw Resident #1 the night of 01/06/23, but LVN A did say she remembered him being present on her shift but did not specify when she last saw him. The ADM stated, prior to this incident, it was a requirement to do a shift report at shift change, but it was not required to do walking rounds at shift change. The ADM stated they did not have a sign out book for residents going on pass, but they had an option in the EMR to mark the residents out on pass and doing this was their policy and procedure. The ADM stated the DON did all the in-servicing after the incident. The ADM stated part of the change they implemented was walking rounds at shift change, which meant that the off-going nurse and oncoming nurse had to physically walk through their halls together and put eyes on every single resident. The ADM stated she, the DON, and the ADON followed along on these rounds at every shift change for a full week to ensure the nurses got into the habit. The ADM stated Resident #1 had no history of exit seeking prior to this incident, and when she spoke to the family about the incident, they all said he could not get far with his level of ambulation. The ADM stated they always performed an elopement assessment with the admission assessment, and Resident #1's elopement assessment had a result of low risk. When asked what was being done to prevent Resident #1 from eloping again, the ADM stated he no longer had access to the patio doors and could not see any patio doors from his current room. The ADM stated that was the biggest and most crucial intervention. The ADM stated they did lab work, and the results showed no abnormal values. The ADM stated he was positive for COVID-19 shortly after that, so it was possible the change in his behavior was related to COVID-19. The ADM stated he had just been on antibiotics for a UTI, so they were sure it was not that. The ADM stated they also did individual counseling with each staff person involved in Resident #1's incident. The ADM stated LVN B took CNA C's word for it and did not check, CNA C did not follow protocol and clearly report the missing resident, and LVN A did not give a thorough enough shift report. The ADM stated they had three people listed in their wandering/elopement risk binder that was placed at both nurse's stations and the front desk, but the other two residents (Residents #2 and #3) had not exhibited those behaviors in a very long time, and Resident #3 was no longer at the facility. The ADM stated the facility did not accept residents with a known history of wandering and elopement. The ADM stated they were a short term, high volume facility, and they were not equipped to monitor residents who had that risk. The ADM stated, if they had a resident with cognitive impairment who began to exhibit exit seeking behavior, they would monitor closely for a week and then begin to have discussions about discharge to a more appropriate facility. Record review of facility in-services reflected the following: 01/07/23 Elopement 01/07/23 Abuse & Neglect 01/07/23 Leave of Absence 01/07/23 Walking Rounds Review of the facility's QAPI Performance Improvement Plan dated 01/07/23 reflected a subcommittee comprised of the ADM, DON, and ADON. It reflected a subject of To ensure safety and acknowledge the presence of residents admitted to facility. It reflected the following changes implemented: 1) In-service staff on high risk patients and preventative measures. 2) All patients on admission will be assessed for elopement risk. 3) Nurses/CNAs are to perform walking rounds during shift changes. 4) Nurses/CNAs round frequently on the halls. It was marked that the QAPI committee approved the plan. Review of Frequent Monitoring Record for Resident #1 dated 01/08/23 to 01/10/23 reflected documentation of checks on Resident #1 each 15 minutes for the 72-hour period. Review of facility policy dated April 2019 and titled Abuse Protocol reflected the following: Missing patient: if a patient is not located within eight hours during a search of the facility, facility grounds, and immediate vicinity, and there are circumstances, which placed the patient's health, safety, and/or welfare at risk. Review of facility policy dated May 2016 and titled Elopement Response Protocol reflected the following: Upon the occurrence of an allotment or suspected elopement, the following steps must be immediately taken: 10. Based on the elopement risk; the patient may be discharged . The facility administrator, facility DON, and the corporate nurse consultant were notified on 01/27/23 at 05:05 PM that an Immediate Jeopardy situation had been identified due to the above failures. The following Plan of Removal submitted by the facility was accepted on 01/29/23 at 11:45 AM and included: [NAME] Air at Teravista Immediate Jeopardy Plan of Removal January 27, 2023 Impact Statement: On 1/27/2023 complaint survey was initiated at [NAME] Air at Teravista, 4105 Teravista Club Dr. Round Rock, TX 78665. On 1/27/2023, the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute an immediate jeopardy to resident health. The facility neglected to provide adequate supervision to 1 patient as he was missing for an extended period of time. Resident was missing for approximately 9 1/2 hours. Immediate action: Please accept this as a Plan of Removal to remove the IJ Identified F689- The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. initiated on 1/27/22 at 5 P.M. Residents that can be affected are those with imminent elopement risk assessments. At this time, the facility had one resident who could be affected. There were two residents that were identified during the investigation that was ambulatory with low BIMs, however, neither resident was triggered for imminent risk due to no history of elopement attempts, wandering, or leaving the community without informing staff. After completing the elopement assessments, on 1/27/2023, facility had one resident identified as imminent risk by the elopement risk assessment. Systematic Approach: 1. Assessment o All residents will have an elopement risk assessment updated by the Director of Nurses, Assistant Director of Nurses, and Patient Care Coordinator on 1/27/23 to identify any current patients that are at imminent risk for elopement. No residents were deemed at imminent risk for elopement. There were two residents identified during the investigation who were ambulatory and had low BIMs; however, neither resident was triggered for imminent risk on a previous or updated elopement assessment due to no history of elopement attempts, wandering, or leaving the community without informing staff. The assessment is a (Electronic Medical Record) Document and includes the following information: The assessment to determine if patient is an imminent risk for elopement. The resident will have to intentionally or unintentionally attempt to leave the community or verbalize a plan to elope the community to be documented in the elopement assessment as an imminent risk for elopement. o Start Date: 1/27/2023. o End Date: 1/29/2023 o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing o Beginning 1/27/23, elopement assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any patient that triggers an imminent risk for elopement, the elopement response protocol will be initiated. The ED and DON will monitor for compliance daily by running an audit of the elopement assessments. o Start Date: 1/27/2023. o End Date: Audits will be completed weekly for 3 months until 4/27/2023 and then monthly on an ongoing basis. o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing ? Beginning 1/27/23, any patient who triggers an imminent risk of elopement, meaning the patient intentionally or unintentionally attempts to leave the community or verbalize a plan to elope the community, will have notification placed in the elopement binder by the Nurse Manager and monitored by Clinical Staff in accordance with the Elopement Response Protocol- A (Facility Company) Policy ? Facility staff will conduct thorough rounds of facility grounds. ? If patient is not found within 15 minutes charge nurse will call the Executive Director. ? Executive Director will call family, police and notify Physician. ? Executive Director will notify HHSC of incident. ? Facility Staff will continue to search for resident until found. ? Once Resident is found a nurse will do head to toe assessment and provide care accordingly. ? In addition, the physician and responsible party will be notified of the results. Until alternative and or safe living arrangements are made the patient will be placed on one-to-one supervision with facility staff. The patient's picture and face sheet will be placed in an elopement binder. Patient care plans will also be updated. The Director of Nursing and/or Nurse Managers will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. o Start Date: 1/27/2023. o End Date: Audits will be completed weekly for 3 months until 4/27/2023 and then monthly on an ongoing basis. o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing 2. In-Services o Clinical Staff were in-serviced by the Director of Nursing and/or Nurse Managers. All new clinical staff will receive the Elopement in service as part of the onboarding orientation process prior to being assigned and providing care to residents. No clinical staff member will be allowed to work in the facility until the above required in-services are completed. Any line staff that does not complete in-service will be terminated by 1/29/2023. o Start Date: 1/27/2023. o End Date: 1/29/2023 o Who will be Responsible: Nurse Managers o Who Will Monitor: Executive Director/Director of Nursing o Shift to Shift Reporting process will be as follows. ? As part of shift to shift report the charge nurse will print the census to identify patients who are on leave and not in the facility. ? At shift change, 6a.m., 2p.m., 10p.m.- the oncoming nurse will conduct walking rounds the outgoing nurse and account for each patient on the census. ? At shift change, 6a.m., 2p.m., 10p.m.- Certified Nurse Aides must conduct walking rounds and visually account for each patient. All new clinical staff will receive the Elopement in service as part of the onboarding orientation process prior to being assigned and providing care to residents on the floor by the Director of Nursing and/or Nurse manager. o Start Date: 1/27/2023. o End Date: 1/29/2023 o Who will be Responsib[TRUNCATED]

Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) out of four residents reviewed for neglect, in that: The facility failed to get Resident #1 to the ER, until four and a half hours after he fell , and hit his head, resulting in a laceration to his eyebrow. He was diagnosed with a subdural hematoma at the hospital. LVN A and LVN B did not check Resident #1's neuros as per facility policy. This failure placed residents at risk of a fall which could lead to brain damage, paralysis, loss of consciousness with decreased breathing effort, and death. Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS assessment, dated 8/2/22, reflected a BIMS of 0, indicating a severe cognitive deficit. It further reflected he utilized a wheelchair and was totally dependent for all ADL's. Review of Resident #1's care plan, revised 8/7/22, reflected he was at risk for falls related to [CONDITION(S)] (stroke) with deficits (right [CONDITION(S)]) with interventions of encouraging him to be in common areas, when in his wheelchair, for maximum staff observation. It further reflected he was at high risk for increased bleeding related to blood thinning agent. Review of Resident #1's physician order, dated 6/30/22, reflected the order for [MEDICATION(S)] (blood thinner) 75 mg (1 tablet) every evening. Review of Resident #1's nursing progress note in his EMR, dated 8/7/22 at 1:12 PM, reflected the following documentation by LVN A: [Resident #1] was sitting up in wheelchair in cafe, when he slid out of wheelchair landing on his right side, hitting his right eyebrow causing a 3cm laceration to his eyebrow and a 3cm x 3cm abrasion to his left elbow. Pressure dressing applied to eyebrow and protective dressing to his elbow. Family notified and requested to send to [Hospital C], NP on-call notified, and order was received to send. Reported called ER, [non-emergency transportation service] notified of transport, all papers ready and patient ready for transport. Neuro checks initiated. Review of Resident #1's neuro checks, dated 8/7/22, reflected neuro checks were done by LVN A at 12:30 PM, 1:00 PM, 1:30 PM, and 2:30 PM; his nuero checks were don by LVN B at 3:30 PM. Review of Resident #1's nursing progress note in his EMR, dated 8/7/22 at 3:55 PM, reflected the following documentation by LVN B: Call placed to [non-emergent hospital transfer company] requesting report as to why [Resident #1] was not picked up and transported. Dispatch reports that it was canceled earlier. This nurse requests to know who was informed at the [facility]. Dispatch unable to respond . I called 911 for transport. 911 arrived shortly after 4:15 PM. They took [Resident #1] by stretcher for follow up/assessment. Review of Resident #1's Incident Report, dated 8/7/22 and completed by LVN A, it reflected at 12:00 PM, Resident #1 had an unwitnessed fall in the cafe next to the nurses station. Review of Resident #1's discharge hospital records, dated 8/7/22, reflected an EMS dispatch timeline: Call received: 4:00 PM On Scene: 4:11 PM Departed Scene: 4:25 PM At Destination (hospital): 4:35 PM The records further reflected the ER doctor's results after testing: Impression: 1. Low-density left cerebral convexity subdural hematoma (brain bleed) which is new from the prior exam and measures up to 1.3 cm in thickness. 2. Right cerebral convexity acute (of abrupt onset) hyperdense subdural hematoma measuring up to 0.2 cm. During an interview on 10/19/22 at 12:35 PM with Resident #1's NP, she stated when a resident fell and hit their head, if there were obvious signs of trauma/bleeding, and especially if they were on a blood thinner, the time to get them to the ER was the sooner the better. This Surveyor asked if she believed it would be different if the resident's neuros were normal. She stated it would not be different because neuros were a gray area - a person could change in seconds. This Surveyor asked the NP if she believed a head injury could go from bad to worse within four hours, and she stated that hours could make all of the difference. She stated Resident #1's fall happened over the weekend. sSo the on-call NP was notified of the incident. She stated he ordered for the resident to be sent to the ER. She stated, in her opinion, the staff at the facility should have ensured the resident had gotten to the ER as soon as possible after the fall. She stated her expectations were that neuros were to be taken every 15 minutes/30 minutes/1 hour (4x each). During an interview on 10/19/22 at 12:57 PM with the DON, this Surveyor asked if it were normal for the facility to wait four hours to get a resident to the hospital after falling and hitting their head . She stated, yes and no; if there was obvious injury and vitals were off, they would call 911 right away. She stated Resident #1 had not been experiencing AMS (Altered Mental Status) and his neuros were okay. She stated she expected neuros to be check per their facility policy. She stated when the nurse contacted the family to notify them of the fall, they requested he be sent to [Hospital C]. She stated they knew if they called 911, they would have taken him to [Hospital D], so that was why they contacted the non-emergency ambulance company. She stated she did not believe that the four hours worsened Resident #1's injury because she had never experienced something like that happening so quickly and all of his neuros had been normal. She stated no in-services or training had been conducted on fall prevention, head injuries, or emergency services since the incident with Resident #1 on 08/07/2022. On 10/19/22 at 1:07 PM, an attempt to call LVN A was made, and a message was left requesting a call back. During an interview on 10/19/22 at 1:14 PM with LVN B, she stated when Resident #1 fell on [DATE] in the dining room, she helped get LVN A get him up and to his room utilizing a hoyer mechanical transfer lift. She stated at that time, he was under the care of LVN A. She stated LVN A got his vitals and contacted the NP, family, and the DON. She stated LVN A also arranged transportation for Resident #1 to be sent to the ER; she contacted a non-emergency transportation service because Resident #1 had not been that bad looking. She stated at 3:00 PM she took over working the hall Resident #1 resided on, and close to 4:00 PM she realized he was still at the facility. She stated she asked LVN A, and she did not know why. She stated she contacted the non-emergent transportation company and they told her the request had been cancelled but could not tell her why. She stated it was then that she contacted 911 for Resident #1 to be transported. During an interview on 10/19/22 at 2:02 PM with the ADM, she stated her expectations were that after a resident fell , that the staff ensured they were safe and without injury. This Surveyor asked the ADM what she thought a proper timeframe would be to send a resident with a head injury prior to a fall to the ER, she stated that it would depend, and that every situation was different. She stated it was the call of the nurses and physician. She stated not getting a resident to the ER when it was necessary could result in AMS or any kind of significant change in their health. She stated the facility did not have any policies on emergency services or head injury protocols. Review of the facility's Fall Management Policy, dated March of 2019, reflected the following: Scheduled Interventions for Fall Management: Q 15/30/1 hour checks Review of the facility's Abuse and Neglect Protocol Policy, dated April of 2019, reflected the following: 1. The Patient has the right to be from abuse, neglect .

Based on interview and record review, the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services to promote healing, prevent infection, and prevent new ulcer from developing for one (1) of three (3) residents reviewed for pressure ulcers (Resident #8). Resident #8 was admitted to the facility with excoriations and abrasions to his sacrum. (The sacrum is a large triangular bone at the base of the lower spine.) The facility nursing staff failed to assess the resident's wounds timely, which resulted in a delay in treatment. Resident #8 developed a deep tissue injury (DTI) pressure ulcer over the course of two and one-half days before his wounds were assessed and treatment orders were obtained. This deficient practice placed the six residents with pressure ulcers at risk of delayed healing, infection, and development of new pressure ulcer. Findings include: Review of Resident #8's face sheet dated [DATE] revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] at 6:34 p.m. with [DIAGNOSES REDACTED]. Review of the Braden Scale - For Predicting Pressure Sore Risk, dated [DATE] and signed by LVN I, revealed Resident #8 was at high risk for development of pressure ulcer. Review of Resident #8's admission Nursing Assessment, dated [DATE] and signed by Licensed Vocational Nurse (LVN) I, read in part: paper thin skin, reddened (a single line was drawn through the word "reddened" and the word "error" was written above the line) excoriated sacrum with 2 small abrasions, skin tears with dressing to bilateral upper extremities, back is clear yet weeping. (There were no measurements for the wounds.) Review of the Physician's Telephone Orders, dated [DATE] and signed by LVN I as the nurse receiving the order from Nurse Practitioner J, revealed the following order: "Wound care nurse to assess sacrum." A single line was drawn through the word "sacrum" and the word "error" was written above the line. Interview on [DATE] at 1:43 p.m. with Nurse Practitioner J revealed facility staff notified her of the skin breakdown on Resident #8's sacrum on the evening of [DATE]. Nurse Practitioner J reported she gave a telephone order for the wound care nurse to assess Resident #8's sacrum. Interview on [DATE] at 1:30 p.m. with LVN I revealed she observed that Resident #8's sacrum was excoriated with two small abrasions on admission to the facility. LVN I stated she notified Nurse Practitioner J of the abrasions on Resident #8's sacrum on [DATE] at 10:00 p.m. LVN I stated the Nurse Practitioner gave her an order to have the Treatment Nurse look at Resident #8's excoriated sacrum. LVN I stated she drew a line through the word "sacrum" in the Physician's Telephone Orders dated [DATE] because "I wanted the Treatment Nurse to look at the resident's whole body." LVN I stated she did not obtain any treatment orders for Resident #8's excoriated sacrum, because the facility had a policy and procedure for treating pressure ulcers. Review of the admission Nursing Assessment, dated [DATE] and signed by LVN I, revealed a body diagram with the following notation: "sacrum 7.8 x 6.5 x 0.1 DTI" LVN I read the notation and stated, "I did not write that." The facility policy titled "Skin & Wound Treatment" ([DATE]) was provided by the Treatment Nurse on [DATE]. The policy read in part (Page 1): This protocol contains suggested interventions. You should work with the Patient's attending physician to implement this protocol by obtaining any necessary physician's orders [REDACTED]. Partial Thickness Wound - Persistent Reddened Area Skin Tears Abrasions Tumors Partial Thickness Dry Wound Dressing Suggestion Guide (Choose 1 of the following) [MEDICATION NAME] Transparent film Hydrogel impregnated gauzes Hydrogel sheet The policy titled "Skin & Wound Treatment" read in part (Page 2): Partial Thickness Wound with Exudate (fluid draining from a wound) Primary Dressing Suggestion Guide (Choose 1 of the following) Light Exudate - Antimicrobial hydrogel Polyacrylate dressing Moderate Exudate - Antimicrobial hydrogel perforated Calcium alginate Foam dressings Heavy Exudate - Silver based cavity paste Antimicrobial powder Calcium alginate The Skin & Wound Treatment policy did not specify any time frames for initiating skin and wound treatments. The policy titled "General Skin Care" (Protocol 1-A) read in part: This protocol contains suggested interventions. You should work with the Patient's attending physician to implement this protocol by obtaining any necessary physician's orders [REDACTED]. This General Skin Protocol must be followed for all Patients. Use appropriate pressure-reducing devices to include but not limited to special care areas...Turn and reposition every two hours or more frequently if indicated by Patient's clinical condition...Any change in the Patient's skin condition must be documented, the physician and responsible party notified. The General Skin Care policy revealed the policy did not specify any time frames for initiating skin and wound treatments. Resident #8's Interim Plan of Care for the month of February 2014 was reviewed with LVN I. LVN I stated the Interim Plan of Care was initiated for Resident #8 on admission to the facility. The Interim Plan of Care reflected the following interventions under the heading Skin Integrity: "Area to buttocks monitored at this time. Wound care facility nurse to eval (evaluate)." There were no other intervention included for this care plan. the care plan did not include the use of a pressure relief mattress, or turning and repositioning. Review of the Skilled Daily Nurses Note dated [DATE] revealed there was no evidence indicating that a skin assessment of Resident #8's sacrum was performed. There was no evidence indicating that the facility's General Skin Care protocol was implemented. Review of the Nurse's Notes for Resident #8 revealed a note dated [DATE], timed 10:15 a.m. and signed by the Treatment Nurse, which reflected the resident had a DTI pressure ulcer on his sacrum that measured 7.8 cm (length), 6.5 cm (width), and 0.1 cm (depth). (The abbreviation "cm" refers to centimeters.) Review of the Physician's Telephone Orders dated [DATE], timed 9:30 a.m. and signed by the Treatment Nurse as the nurse receiving the order from Nurse Practitioner J, revealed the following treatment order for Resident #8's sacral pressure ulcer: cleanse with normal saline, pat dry, and then apply skin prep, [MEDICATION NAME] dressing, and change Monday, Wednesday, and Friday. Interview on [DATE] at 1:20 p.m. with the Treatment Nurse revealed she first observed the pressure ulcer on Resident #8's sacrum on the morning of [DATE]. The Treatment Nurse stated Resident #8 had a sacral DTI pressure ulcer, and there were no treatment orders for the pressure ulcer. The Treatment Nurse stated she called Nurse Practitioner J immediately and obtained treatment orders for the pressure ulcer. The Treatment Nurse stated she was unsure why the staff had not called her sooner. The Treatment Nurse stated she would have obtained treatment orders sooner. The Treatment Nurse stated Resident #8's pressure ulcer was at risk of infection due to the resident's bowel incontinence. The Treatment Nurse stated the following measures were initiated on [DATE]: Facility staff initiated a new care plan to address Resident #8's pressure ulcer on [DATE]. The Wound Care Specialist was notified on [DATE], and the specialist evaluated Resident #8's pressure ulcer on [DATE]. Review of the admission Nursing Assessment, dated [DATE], with the Treatment Nurse revealed the Treatment Nurse altered the admission Nursing Assessment by documenting the measurements of Resident #8's sacral DTI pressure ulcer ("sacrum 7.8 x 6.5 x 0.1 DTI") on the body diagram. The Treatment Nurse did not initial or date the entry or indicate in any way that the pressure ulcer measurements were obtained on [DATE], not on [DATE]. Review of the Wound Assessment form, dated [DATE] and signed by the Treatment Nurse, revealed the Treatment Nurse documented that Resident #8 had a dark red/purple-colored deep tissue injury pressure ulcer with a slight odor and red-colored fluid draining from the wound. The wound measurements were 7.8 cm (length), 6.5 cm (width), and 0.1 cm (depth). The Treatment Nurse stated she did not accurately document the date she performed the wound assessment. The Treatment Nurse stated she performed the initial wound assessment on [DATE], not on [DATE]. Review of the Pressure Ulcer Prevention Care Plan dated [DATE] revealed Resident #8 was at high risk of developing pressure ulcer. The care plan reflected the following interventions: pressure reducing mattress, pressure reducing equipment in chair, turn every two hours, assess for appropriate footwear, skin protocols, barrier cream, encourage out of bed, off-load all boney prominences, float heels for total pressure relief, all therapy disciplines to screen and evaluate and treat as indicated, review/obtain pre-[MEDICATION NAME]/[MEDICATION NAME] and complete blood count, notify physician of abnormal labs, multivitamin with minerals every day, lower head of bed to turn and reposition, and utilize draw-sheet. Review of the Physician's Telephone Orders dated [DATE] revealed the following orders: Vitamin C 500 mg (milligrams) one tablet by mouth two times daily for wound healing; multi-vitamin with minerals one tablet by mouth one time daily for wound healing; pre-[MEDICATION NAME] and [MEDICATION NAME] levels; and dietary consultation. Review of the Wound Care Follow-Up form, dated [DATE] and signed by the Wound Care Specialist, revealed Resident #8 had an unstageable pressure ulcer of the sacrum that measured 7.8 cm in length, 6.5 cm in width, and 0.2 cm in depth. Treatment recommendations included a change in wound treatment orders. Review of the Physician's Telephone Orders dated [DATE] revealed the following treatment order for Resident #8's sacral pressure ulcer: cleanse with normal saline, pat dry, and then apply Skin-Prep skin barrier, [MEDICATION NAME] skin protectant paste, calcium alginate dressing, border dressing and change daily. During an interview with the Director of Nursing on [DATE] at 2:00 p.m., she stated that the nurses should have notified the physician of Resident #8's skin condition and obtained treatment orders per facility policy. Review of the Skilled Daily Nurses Note, dated [DATE] and timed 06:30 a.m., revealed Resident #8 exhibited symptoms of difficulty breathing, bleeding of the mouth, and decrease in responsiveness. At 7:00 a.m., Resident #8 was transported to the local hospital by emergency medical services personnel. Review of the hospital Discharge Summary dated [DATE] revealed Resident #8 was admitted to the hospital on [DATE]. The death summary reflected a principle [DIAGNOSES REDACTED]." Resident #8 had a sacral pressure ulcer on admission to the hospital. Resident #8 expired on [DATE]. Review of an Addendum was added and signed on [DATE]. The addendum reflected that "The previously dictated discharge summary/death note for this patient on February 7, 2014 had been inadvertently signed by me before I could further expand on the broad differential [DIAGNOSES REDACTED]. The possible etiologies include recurrent urinary tract infection, possible recurrent aspiration, and also [MEDICAL CONDITION] as a result of decubitis ulcers. Review of the In-Service Training Report dated [DATE] revealed facility nurses attended training on the topic of skin condition and treatment orders. The training report read: "Upon admission, if any skin breakdown or skin concerns (are) noted, make sure MD/NP (physician/nurse practitioner) are notified and that skin treatments are ordered and put into place until wound/treatment nurse can assess. If at any time skin breakdown or concerns are noted on existing residents, notify MD/NP and put treatment orders in place until treatment/wound care nurse can assess." A resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, so the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. (Kosiak M. Etiology of decubitus ulcers. Arch Phys Med Rehabil. 1961 Jan; 42:,[DATE].) Sepsis is an illness in which the body has a severe response to bacteria or other germs. (National Center for Biotechnology Information <http://www.ncbi.nlm.nih.gov/> website, U.S. National Library of Medicine <http://www.nlm.nih.gov/> 8600 Rockville Pike, Bethesda MD, USA) The Form CMS-672 dated [DATE] reflected the number of residents with pressure ulcers was six (6).