Every finding on record at Bells Nursing and Rehabilitation Center

Based on facility policy review, observation, and interview, the facility failed to ensure that the resident's (Resident #5) environment remained free of accident hazards during smoking. The findings include: 1. Review of the facility policy titled, Smoking Policy - Residents, dated 3/30/2026, revealed .This facility has established and maintains safe resident smoking practices.Metal containers are available in smoking areas.Ashtrays are emptied only into designated receptacles. 2. Observation of the outside patio at the designated Resident smoking area on 8/3/2026 at 3:09 PM, revealed 4 ashtrays without lids that made them not noncombustible and 2 red smoking receptacles for disposal of cigarettes and ashes that did not close completely, which prevented them from being noncombustible. The facility staff was observed placing the cigarettes in the receptacles for the Residents. During an observation and interview on the outside patio in the designated Resident smoking area on 8/3/2026 at 4:45 PM, the Administrator was shown the ash trays and smoking receptacles. The Administrator was asked can you tell me what types of containers are supposed to be available for smokers. The Administrator stated, .metal containers for the ashes, then dump [cigarette and ashes] to the red container . The Administrator was asked, are the containers supposed to be noncombustible. The Administrator stated, .yes, they are . The Administrator was asked if the ashtrays and red cans were noncombustible since they did not have lids and did not close tightly. The Administrator stated, .yes they are because they are metal . The Administrator was asked if they should have lids that seal and close tight. The Administrator stated, .I don't think so . The Administrator was asked if the lid on the red cans should be able to self-close completely.Yes, they should. They probably just need a little adjustment . Random observation of the outside patio in the designated smoking area on 8/4/2026 at 8:30 AM, revealed the 4 ashtrays had been removed as well as the 2 red receptacles for disposal of cigarette waste. In place of the receptacles that had been removed were two chimney type receptacles with small openings at the top where cigarette butts could be placed but were not easily accessible to the resident. Resident #5, Beautician A and Beautician B were unaware the ashtrays had been removed and did not know of any new procedures for residents who smoke. Beautician B went to ask maintenance about the ashtrays. Beautician B returned stating, .I asked maintenance .they didn't know they were gone either . Resident #5 was observed disposing of ashes on the ground reaching behind her attempting to flick the ashes away from the designated smoking area. The facility failed to provide proper disposal receptacles for cigarette waste to prevent accidents hazards.

Based on facility policy review, medical record review, and interview, the facility failed to ensure timely Advanced Beneficiary Notice (ABN) was given regarding Medicare eligibility and coverage for 2 of 3 (Residents #26 and #78) sampled residents reviewed for ABNs. The findings include: 1.Review of the facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notice, dated 9/2022, revealed .If a resident's Medicare covered Part A stay or when all of part B therapies are ending, a notice of Medicare Non-coverage .is issued to the resident at least 2 calendar days before benefits end . 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Dementia, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was severely cognitively impaired. Review of the facility's Notice of Medicare Non-Coverage form revealed Resident #26's Medicare service end date was 6/24/2026, and Resident #26 signed the form on 7/3/2026. 3. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Depression and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the facility's Notice of Medicare Non-Coverage form revealed Resident #78's Medicare service end date was 3/6/2026, and Resident #78 signed the form on 3/6/2026. During an interview on 8/4/2026 at 1:13 PM, the Administrator was asked how many days notice do you give for an ABN. The Administrator stated, I don't know . During an interview on 8/5/2026 at 10:00 AM, the Social Work Director was asked how many days notice do you give for an ABN. The Social Work Director stated, Two days before discharge . The facility failed to ensure proper notice was given to allot time for appeal process.

Based on facility policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 3 of 85 (Resident #23, #40, #55) residents' rooms reviewed for environment. The facility had 55 occupied resident rooms.The findings include: 1.Review of the facility policy titled, Homelike Environment, dated 8/12/2022, revealed .Residents are provided with a safe, clean, comfortable and home like environment.The staff and management maximizes to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. 2.Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Dementia, and Depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she had severely impaired cognition. Observation in the resident's room on 8/3/2026 at 10:54 AM, 8/4/2025 at 4:45 PM and 8/5/2026 at 2:52 PM, revealed the second drawer of Resident #23's dresser was leaned over, and it had a long scratch exposing the material underneath. During an observation and interview in Resident 23's room on 8/6/2026 at 8:32 AM, the Maintenance Supervisor was asked about Resident #23's bedside dresser drawer. The Maintenance Supervisor stated, The hinge is bent . During an observation and interview in Resident #23's on 8/6/2026 at 8:40 AM, the Administrator was asked to about the resident's bedside dresser drawer. The Administrator stated, The drawer is leaning, it has hinges, it has been here awhile.it needs to be adjusted and touched up. 3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Parkinson's, Cerebral Infarction, and Pain. Review of the admission MDS assessment dated [DATE], revealed Resident #40 scored a 9 on the BIMS assessment, which indicated she had moderately impaired cognition. Observation in the resident's room on 8/3/2026 at 8:46 AM and 8/5/2026 at 3:04 PM, revealed Resident#40's bedside dresser's second drawer was leaned to one side. During an observation and interview in the resident's room on 8/6/2026 at 8:26 AM, the Maintenance Supervisor was asked to about Resident #40's bedside dresser's second drawer. The Maintenance Supervisor stated, The dresser drawer is off track, leaning over to the side. 4. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Diabetes, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #55 scored a 12 on the BIMS assessment, which indicated she had moderately impaired cognition. During an observation and interview in Resident #40's and Resident #55's shared bedroom on 8/6/2026 at 8:55 AM, the Administrator was asked to about Resident #40's bedside dresser. The Administrator stated, We will look at the dresser to see if we can make some adjustments. The Administrator was asked about Resident #55's wall. The Administrator stated, It has paint peeling.someone was called and came Monday and then he came Tuesday. The facility failed to provide residents with a homelike environment.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow orders for oxygen administration for 1 of 1 (Resident #44) residents reviewed for respiratory care. The findings include: Review of the facility policy titled, Oxygen Administration, revised 5/2026, revealed .Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration.Review the physician's order .for oxygen administration .start the flow of oxygen at the rate prescribed by the physician . Review of the Physician's Order dated 10/21/2025, revealed .OXYGEN AT 2 LITERS PER MINUTE [lpm] BNC [By Nasal Cannula] as needed for shortness of breath [SOB] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #44 was unable to be assessed for the Brief Interview for Mental Status (BIMS) assessment. Review of the Care Plan dated 7/31/2026, revealed .Administer O2 @ [at] 2L/BNC as needed for SOB. Observation in the resident's room on 8/3/2026 at 8:44 AM and on 8/4/2026 at 7:49 AM, revealed Resident #44 wearing oxygen at a rate of 3.5 L/M [Liters per minute] BNC. During an interview on 8/4/2026 at 7:50 AM, Licensed Practical Nurse (LPN) C was asked what rate Resident #44's oxygen is ordered to be administered. LPN C stated, Her order is for 2/LPM. LPN C was asked to accompany the surveyor to Resident #44's room. LPN C was asked can you tell me what her (Resident #44) O2 rate is set on. LPN C stated, It is on 3.5 [liters per minute]. LPN C was asked if 3.5/LPM was the correct rate. LPN C stated, No ma'am. LPN C was asked if she should be checking the oxygen rate when she entered the resident's room. LPN C stated, Yes ma'am, I should. During an interview on 8/4/2026 at 8:01 AM, the Director of Nursing (DON) was asked if a resident has an order for oxygen at 2/LPM would you expect your nurses to verify that the rate is correct. The DON stated Yes, ma'am, I would. The facility failed to ensure staff followed Physician's orders for oxygen administration for Resident #44.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when 1 of 5 (Licensed Practical Nurse (LPN) C staff left medication unattended and unsecured on 1 of 5 (200 East Back Hall Medication Cart) medication storage carts, and when staff failed to ensure a medication was labeled for 1 of 1 (Resident #25) residents observed during a random observation. The findings include: 1.Review of the facility's policy titled, Administering Medications, dated 11/2017, revealed, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. It may be kept in the doorway of the resident's room, with all open drawers facing inward. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward signs must be inaccessible to residents or others passing by. Review of the facility's policy titled, Intravenous Administration of Fluids and Electrolytes, dated 5/2015 revealed .The purpose of this procedure is to provide guidelines for the state and aseptic administration of intravenous fluids and electrolytes for hydration.For continuous therapy .mark solution container with label that states when bag was started.use a label or tape.Never write directly on the bag with ink or marker. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia, Diabetes, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she had moderately impaired cognition. Resident #11 was assessed for receiving Insulin. Review of the Physician's Order dated 7/24/2026, revealed Resident #11 had an order for Novolin R insulin (medication used to lower high blood sugar) to be administered before meals and bedtime. The dosage was determined by a sliding scale (a range of results that determines the dosage). Observation and interview at the 200 East Back Hall Medication Cart on 8/4/2026 at 10:43 AM, revealed LPN C prepared Novolin R insulin, gathered supplies and entered Resident #11's room. LPN C left the Novolin R insulin on top of the 200 East Back Hall Medication Cart. LPN C closed the resident's door and administered the insulin, placed the insulin needle in the sharps container, removed and placed gloves in the trash, performed hand hygiene and returned to the 200 East Back Hall Medication Cart. LPN C was asked should you have left the insulin out of sight, unattended and unsecured, on top of the medication cart. LPN C stated, No. LPN C placed the Novolin R insulin vial back in it's box and placed it in the drawer of the 200 East Back Hall Medication Cart and locked the cart. During an interview on 8/6/2026 at 9:50 AM, the Director of Nursing (DON) was asked if medications should be left on top of the medication cart, unattended and unsecured. The DON stated No. The DON was asked how medications should be stored during medication administration when not in use. The DON stated, They should be stored in the drawer of the locked medication cart. 3.Review of the medical record revealed Resident #25 was admitted to the facility on admitted on [DATE], with diagnoses including Aphasia, Dementia, and Cerebral Infarction. Review of the admission MDS assessment dated [DATE], revealed Resident #25 scored a 3 on the BIMS assessment, which indicated she had severely impaired cognition. Review of the Order Summary Report dated 8/4/2026, revealed Resident #25 had an order for Dextrose(sugar)-Sodium Chloride (salt) (clear liquid form of sugar and salt) to be administered intravenously (IV) (by way of the vein) at a dial rate of 75 milliliters per hour (ml/hr) every shift for 6 days. A random observation in Resident #25's room on 8/4/2026 at 4:14 PM, revealed an unlabeled, undated bag of Dextrose-Sodium Chloride IV fluids running at a dial rate of 75ml/hr. The facility failed to label the medication with a start time and date. Observation and interview in Resident #25's room on 8/4/2026 at 4:27 PM, revealed Resident #25 had an unlabeled, undated bag of Dextrose-Sodium Chloride IV fluids infusing intravenously at a dial rate of 75ml/hr. LPN F was asked about the unlabeled medication. LPN F stated, .the IV fluids were started on day shift today. LPN F was asked should Resident #25's bag of Dextrose-Sodium Chloride fluids be labeled. LPN F stated, Yes it should be labeled with a room number and day and time of when it was initiated. During an interview on 8/6/2026 at 10:22 AM, the Regional Nurse was asked should Resident #25's bag of IV fluids be labeled when it is running and how should it be labeled. Regional Nurse stated, The IV fluids should have a label. The nurse should get a label, write the rate, date, and time on the label and place it on the IV bag. The facility failed to ensure medications were appropriately labeled.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain accurate medical records related to treatment administration for 2 of 3 (Resident #7 and Resident #54) residents reviewed for wound care. The findings include: 1. Review of the facility policy titled, Wound Care Policy, dated October 2010, revealed .the date and time the wound care was given.the name and title of the of the individual performing the wound care.the signature and title of the person recording the data. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Pressure Ulcer of Sacral Region, Dementia, Anxiety, Hypertension, and Osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 was unable to be assessed for the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was severely cognitively impaired. Resident #7 was assessed for an unhealed pressure ulcer stage 3 and for an unstageable pressure ulcer with slough and eschar. Review of the Physician's Order dated 7/24/2026, revealed .Cleanse Left buttock with DWC [Dakins Wound Cleanser (non-antibiotic wound care solution)], apply collagen powder (sterile, protein-based product that promotes wound healing), silver alginate (wound dressing to soak up wound fluid and help prevent infection), and cover with dry dressing daily. Review of the Treatment Administration Record (TAR) For May 2026, revealed no wound care was provided on 5/3/2026, 5/11/2026, and 5/22/2026 as ordered by the physician. Review of the TAR For June 2026, revealed no wound care was provided on 6/6/2026 and 6/7/2026 as ordered by the physician. Review of the TAR For July 2026, revealed no wound care was provided on 7/3/2026 as ordered by the physician. 3. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Abscess of Tendon Sheath, Osteoarthritis and Age-Related Physical Debility. Review of the quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 14 for BIMS assessment, which indicated she was cognitively intact. Resident #54 was assessed for an unhealed pressure ulcer stage 3. Review of the Physician's Order dated 6/27/2026, revealed .Cleanse Right lateral shin w/ [with] DWC, pat dry, apply betadine and cover with dry dressing daily every day shift for Unstageable DTI [Deep Tissue Injury]. Review of the May 2026 TAR revealed no wound care was provided on 5/9/2026 as ordered by the physician. During an interview on 8/5/2026 at 3:50 PM, the Wound Nurse was asked if she expected wound care to be provided when she was not in the facility. The Wound Nurse stated, Yes ma'am, I would. The Wound Nurse was asked who does the wound care when you are not here. The Wound Nurse stated, .They try to get [named LPN E], but if she is not available, they call the prn (as needed) staff, or the floor nurses would be responsible. The Wound Nurse was asked if there were missing treatment's (for Resident #7 and #54) on 5/3/2026, 5/9/2026, 5/11/2026, 5/22/2026, 6/6/2026, 6/7/2026, and 7/3/26. The Wound Nurse stated, .there were [was] no documentation that stated it was done. The Wound Nurse was asked if missed treatments could cause the wound to worsen. The Wound Nurse stated, Yes, it can. The Wound Nurse was asked if wound care was provided on the weekends. The Wound Nurse stated, .Yes, there should always be. During an interview on 8/5/2026 at 4:09 PM, the Director of Nursing (DON) was asked if the nurse on duty should notify the physician of missed treatments. The DON stated Yes, we should. The DON was asked if there should be blanks in the TAR when a resident misses treatments. The DON stated, There should be a code they put in there.

Based on facility policy review, PreOP.com educational guide review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 1 of 1 (Certified Nurse Assistant (CNA) G) failed to ensure proper handling of soiled linen and when staff failed to ensure proper positioning of an indwelling urinary catheter for 1 of 2 (Resident #8) sampled residents reviewed for indwelling urinary catheter. The findings include: Review of the facility policy titled, Laundry and Bedding, Soiled, dated 4/2013, revealed .Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control.Contaminated laundry is bagged or contained at the point of collection.where it was used. Review of the facility policy titled, Catheter Care, Urinary, dated 4/2013, revealed .to prevent catheter-associated urinary tract infections.maintain a closed drainage system. 2. Review of the undated PreOP.com education guide titled, Closed Urinary Drainage System, revealed . A closed urinary drainage system consists of a catheter inserted into the urinary bladder and connected via tubing to a drainage bag. The catheter is retained in the bladder by an inflated balloon .The drainage bag can be attached to the bed frame, should never touch the floor, and should always be kept below the level of the patient's bladder . 3. Review of the medical record reveal Resident #8 was admitted to the facility on [DATE], with diagnoses including Dementia, Presence of Urogenital implants. and Heart Failure. Review of the Physician's Order dated 7/13/2026, revealed Resident #8 had an order for an indwelling urinary catheter. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he had moderately impaired cognition. Resident #8 was dependent upon staff for toileting hygiene and had an indwelling urinary catheter. Review of the Care Plan dated 7/17/2026, revealed Resident #8 had an indwelling urinary catheter and risk for infection will be minimized. A random observation in the resident's room on 8/3/2026 at 3:17 PM, revealed Resident #8's catheter bag was hung from a bar under his wheelchair and lying on the floor. During an observation and interview in the resident's room on 8/3/2026 at 3:22 PM, Resident 8's catheter bag was hung from a bar under his wheelchair and laying on the floor. Licensed Practical Nurse (LPN) H was shown the catheter bag and asked if it should be lying on the floor. LPN H stated, It should not be on the floor, I am placing it on the side bar of his wheelchair. 4. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Pain, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 15 on BIMS assessment, which indicated she had intact cognition. During an observation and interview in the resident's room on 8/3/2026 at 9:00 AM, towels were observed on Resident #78's floor. CNA G was asked about the towels on the resident's floor. CNA G stated, They are used towels from third shift. During an interview on 8/3/2026 at 9:21 AM, CNA G was asked if soiled dirty towels should have been left on Resident #78's floor. CNA G stated, No. During an interview on 8/6/2026 at 9:52 AM, the Director of Nursing (DON) was asked what staff should do with soiled linen. The DON stated, It should be placed in a pillowcase or a linen bag and then taken to the dirty linen closet. The DON was asked if soiled linen should be on the resident's floor. The DON stated, No. The DON was asked if a resident's catheter bag should be laying on the floor. The DON stated, No. The DON was asked when a resident is in a wheelchair, where should his catheter bag be. The DON stated, Under the wheelchair, but not on the floor.

Based on policy review, medical record review, and interview, the facility failed to identify, assess, report, and contact a provider for an injury of unknown origin for 1 of 3 (Resident #94) sampled residents reviewed for allegations of abuse. Resident #94, a severely cognitively impaired, vulnerable resident, dependent on staff for transfers was found with her right arm lodged in the opening of the armrest of the wheelchair on 7/13/2025. Later the same day staff observed bruising from her elbow to her wrist. An x-ray obtained on 7/14/2025 revealed a fracture of the right humerus (upper arm). The facility's failure to immediately assess Resident #94's injury of unknown origin, report the injury to Management Staff, and contact a provider regarding the injury of unknown origin and change of the Resident's condition, resulted in actual Harm to Resident #94. The findings include: 1. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 10/28/2022, revealed .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.The state licensing /certification agency responsible for surveying/ licensing the facility.Immediately is defined as.within two hours of an allegation involving abuse or result in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of the residents.All allegations are thoroughly investigated. The administrator initiates investigations. Review of the facility policy titled, Accidents and Incidents-Investigating and Reporting, dated 7/2018, revealed .All accidents or incidents involving residents .shall be investigated and reported to the Administrator.The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The following data.shall be included in the Incident Report form.nature of the injury /illness.bruise, fall.The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall complete an Incident Report form and submit the original to the Director of Nursing Services.The Director of Nursing shall ensure that the Administrator receives a copy of the Incident Report for each occurrence. 2. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Aphasia, Contracture of Right Wrist and Right Hand, Cerebral Infraction, and Hemiplegia and Hemiparesis Affecting Right Dominant Side. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a brief interview for mental status could not be conducted, the resident was rarely/never understood, and cognitive skills for daily decision making were severely impaired. Resident #94 was dependent upon staff for toileting, bathing, dressing, hygiene, and transfers. Review of the Nurse's Note for Resident #94 dated 7/13/2025 at 10:56 AM, revealed .CNA [Certified Nurse Assistant] came up to the nurse station and stated Resident [#94] just almost slid out of her wheelchair but [CNA B] was able to reposition resident and wheelchair before [Resident #94] slid out completely. Review of the Nurse's Note for Resident #94 dated 7/14/2025 at 1:07 AM, revealed .Staff reported to this nurse [Licensed Practical Nurse (LPN) D] that resident's right arm was discolored/bruised from elbow to wrist. Upon assessment dark red discoloration noted on resident's forearm measuring 24 cm [centimeters] in length by 7 cm in width. Resident denies complaint of pain or discomfort concerning affected area.[Medical Director] notified. No new orders. Resident suffers from aphasia and was not able to communicate how injury may have occurred. Previous shift had already left for evening. Staff instructed to use caution when repositioning resident. The facility was unable to provide an assessment or any other documentation regarding the incident where Resident #94's arm was lodged in the wheelchair during the dayshift on 7/13/2025 or during the evening shift regarding the bruising on the resident's right arm that was found approximately 7:20 PM until 7/14/2025 at 1:07 AM. Review of the undated and signed Employee Investigation Interview Form signed by CNA B revealed, .Date/time of incident 7-13-25 [7/13/2025].[Resident #94] was sliding out of her wheelchair her bedside table was still in front of her .her stroke arm was not in normal position . Review of the undated and signed Employee Investigation Interview Form signed by CNA E revealed, .Date/time of incident 7-13-25 7:20 pm [PM].[Resident #94].in bed.came in Sunday at 7:00 PM, Check resident at 7:20 PM notice large bruise on Right arm, had not Did [done] any care at that time, notified the nurse. Review of the Nurse Practitioner (NP) Note dated 7/14/2025 at 3:25 PM, revealed .Patient [Resident #94] complaints of spontaneous ecchymoses [bruising]. This has been noted for one to two days.bruising is on her right upper arm. She slid down in chair this weekend.orders given for right humerus x-ray. Review of the Nurse's Note for Resident #94 dated 7/14/2025 at 4:56 PM, revealed .[NP] in facility on this date for visit with resident regarding follow up on bruising to right upper arm.orders as follows obtained X-ray of right humerus. Review of the Radiology Results Report for Resident #94 dated 7/15/2025 at 9:16 AM, revealed HUMERUS.Acute appearing fracture of the surgical neck as noted. Review of the Nurse's Note for Resident #94 dated 7/15/2025 at 12:58 PM, revealed .[NP] reviewed right humerus x-ray results obtained on 7/15/25 [2025]. New orders.Transfer to [named hospital] on this date for possible surgical neck fracture.Bruising remains to right upper arm related to incident of sliding down in chair over the weekend. Review of the (Named Hospital) Emergency Department (ED) Triage Notes dated 7/15/2025, revealed .Patient [Resident #94] presents.from [Named nursing home] for right arm bruising and humoral fracture. Staff advised EMS [Emergency Medical Service] that they noticed the bruising yesterday and performed an X-ray which resulted .with noted fracture. Staff advised that they are unsure how the patient sustained this injury as patient is bed bound and paralyzed on the right side-right also severely contracted at baseline. Review of the signed witness statement by CNA B dated 7/15/2025, revealed .resident [#94] was sliding out of her wheelchair. she had her contracted arm in the opening of the wheelchair by [the] armrest. with her feet on the wheels of bedside table, [her] left arm was extended cross [across] her bed rail.we got her back into the wheelchair.Brought resident out to the charge nurse and reported what happened, left resident [#94] at nurse station . During a telephone interview on 8/12/2025 at 2:18 PM, Licensed Practical Nurse (LPN) C confirmed she was told by CNA B, on 7/13/2025, at approximately 11:00 AM, that Resident #94 had slid down in the wheelchair. LPN C confirmed she failed to assess the resident, failed to complete an incident report, failed to report the incident to administration and the oncoming staff, and failed to obtain witness statements. During a telephone interview on 8/12/2025 at 2:51 PM, CNA B confirmed Resident #94 was found, during the morning on 7/13/2025, with her contracted right arm lodged in the opening under the armrest of the wheelchair. CNA B confirmed she did not write a witness statement on the day of the incident. During an interview on 8/13/2025 at 8:16 AM, the Regional Nurse Consultant confirmed she and the management staff were not notified of the bruise on Resident #94's forearm until 7/14/2025. The Regional Nurse Consultant confirmed the nurse should have reported the bruises to the Director of Nursing (DON) when it was found on 7/13/2025 at 7:20 PM, as an injury of unknown origin. The Regional Nurse Consultant confirmed an injury of unknown origin should be reported to the DON and the Administrator at the time it is discovered, and it should be reported to the state (State Survey Agency) when it is discovered. The Regional Nurse Consultant confirmed LPN C should have assessed Resident #94, documented the incident, and completed an incident report when informed the resident was found with her right arm ledged in the opening under the armrest of the wheelchair. During a telephone interview on 8/13/2025 at 9:25 AM, LPN D confirmed he failed to immediately notify the provider and the DON when the bruises were found. During a telephone interview on 8/14/2025at 12:06 PM, CNA E confirmed on 7/13/2025, at approximately 7:20 PM, she observed a purple-colored bruise on Resident #94's right forearm and upper right arm. During a telephone interview on 8/14/2025 at 3:35 PM, the NP confirmed when staff observe bruising, they should report their findings. The NP was asked do you know what caused the bruise. The NP stated .we had discussed [Resident #94] had slid down in wheelchair. The NP confirmed she was not notified until 7/14/2025 of the bruising found on 7/13/2025. The facility failed to assess Resident #94, failed to complete an incident report, and failed to report the injury to management staff and the provider when the injury was found on 7/13/2025 at approximately 7:20 PM.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when food was found opened and undated. The census was 87 with 87 residents receiving a meal tray from the kitchen. The findings include: Review of the facility policy titled, Food Receiving and Storage, revised 11/2018, revealed .Foods shall be received and stored in a manner with safe handling practices.All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date or open date).Other opened containers must be dated and sealed or covered during storage. Observation during the initial tour in the kitchen on 8/11/2025 at 8:50 AM, revealed the following in the walk-in refrigerator: a. 1 gallon of opened and undated mayonnaise b. 1 bag of opened and undated sliced cheese c. 1 gallon of opened and undated pickles Observation during the initial tour in the kitchen in the walk-in freezer on 8/11/2025 at 8:55 AM, revealed a box of single serve ice cream, opened and undated. During observation and interview in the kitchen on 8/12/2025 at 11:03 AM, the Certified Dietary Manager (CDM) confirmed the staff needed more education when the following revealed: a. 1 opened and undated 5-pound container of granulated onions b. 1 opened and undated 16-ounce bottle of imitation banana extract c. 1 opened and undated 16-ounce bottle of pure lemon extract During an interview on 8/11/2025 at 10:00 AM, the CDM confirmed that all items should be dated when opened.

Based on policy review, medical record review, observation, and interview, the facility failed to report an injury of unknown origin and an allegation of misappropriation of resident property to the appropriate agencies for 2 of 3 (Resident #78 and #94) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 10/28/2022, revealed .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.The state licensing /certification agency responsible for surveying/ licensing the facility.Immediately is defined as.within two hours of an allegation involving abuse or result in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of the residents.All allegations are thoroughly investigated. The administrator initiates investigations. 2. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypertension, and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #78 had intact cognition. During an interview on 8/12/2025 at 7:56 AM, Resident #78 stated .I have $42.00 missing. I think my roommate may have gotten it and threw it away .and six pair of pants missing about 2-3 weeks ago. Resident #78 confirmed she reported the missing money to a Certified Nursing Assistant (CNA) and the missing clothing to laundry staff. During an interview on 8/12/2025 at 8:33 AM, CNA G was asked if Resident #78 ever told her that she had money missing. CNA G stated, She [Resident #78] told me it was a dollar out of her drawer but did not know if she misplaced it or if someone took it about 2 weeks ago. CNA G confirmed she told a floor nurse but did not tell any other staff member. During an interview on 8/12/2025 at 8:27 AM, the Administrator was informed that Resident #78 stated she had missing money and thought her roommate may have gotten it. During an interview on 8/13/2025 at 3:10 PM, the Administrator confirmed he had not reported that Resident #78 was missing $42 dollars to the State Survey Agency or any other agency. 3. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Aphasia, Contracture of Right Wrist and Right Hand, Cerebral Infraction, and Hemiplegia. Review of the quarterly MDS assessment dated [DATE], revealed an interview for mental status could not be conducted due to Resident #94 was severely impaired. Resident #94 was dependent upon staff for toileting, bathing, dressing, hygiene, and transfers. Review of the Nurse's Note dated 7/14/2025 at 1:07 AM, revealed, . Staff reported to this nurse that resident's right arm was discolored/bruised from elbow to wrist. Upon assessment dark red discoloration noted on resident's forearm measuring 24 cm [centimeters] in length by 7 cm in width. Resident denies complaint of pain or discomfort concerning affected area.[named provider] notified. No new orders. Resident suffers from aphasia and was not able to communicate how injury may have occurred. Previous shift had already left for evening. Staff instructed to use caution when repositioning resident. Review of the Radiology Results Report dated 7/15/2025 at 9:16 AM, revealed Resident #94 had a fracture to the right humerus (upper arm). Review of the [named hospital] ED [Emergency Department] Triage Notes, dated 7/15/2025 at 1:51 PM, revealed Resident #94 was admitted to the ED with bruising to the right arm and a humoral fracture as evident by an x-ray that was performed at the nursing home. The staff at the facility reported to Emergency Medical Services (EMS) that the bruising was observed on 7/14/2025 and that staff was unsure how the injury occurred because .patient [Resident #94] is bed bound and paralyzed on the right side-right also severely contracted at baseline . During an interview on 8/13/2025 at 8:16 AM, The Regional Nurse Consultant confirmed all injuries of unknown origin should be reported by staff when found. The Regional Nurse Consultant confirmed Resident #94 had an injury of unknown origin on 7/13/2025 and management staff was not made aware until 7/14/2025. During a telephone interview on 8/13/2025 at 9:25 AM, Licensed Practical Nurse (LPN) D confirmed on 7/13/2025 after shift change at 7:20 PM, he was asked to come see a bruise on the right forearm on Resident #94. LPN D described the bruise as dark red from the wrist to the elbow. LPN D confirmed he failed to immediately notify the provider and the DON. During an interview on 8/14/2025 at 3:28 PM, the Administrator confirmed allegations of abuse, injuries of unknown origin, and allegations of misappropriation of resident property, should be reported to the state.

Based on policy review, medical record review, and interview, the facility failed to perform a complete and thorough investigation for 1 of 3 (Resident #94) sampled residents reviewed for allegations of abuse. Resident #94, a severely cognitively impaired, vulnerable resident, dependent on staff for transfers was found with her right arm lodged in the opening of the armrest of the wheelchair on 7/13/2025. Later the same day staff observed bruising from her elbow to her wrist. An x-ray obtained on 7/14/2025 revealed a fracture of the right humerus (upper arm). The findings include: 1. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 10/28/2022, revealed .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.All allegations are thoroughly investigated. The administrator initiates investigations. Review of the facility policy titled, Accidents and Incidents-Investigating and Reporting, dated 7/2018, revealed .All accidents or incidents involving residents .shall be investigated and reported to the Administrator.The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The following data.shall be included in the Incident Report form.nature of the injury /illness.bruise, fall.The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall complete an Incident Report form and submit the original to the Director of Nursing Services.The Director of Nursing shall ensure that the Administrator receives a copy of the Incident Report for each occurrence. 2. Review of the medical record revealed Resident #94 was admitted to the facility on [DATE], with diagnoses including Aphasia, Contracture of Right Wrist and Right Hand, Cerebral Infraction, and Hemiplegia and Hemiparesis Affecting Right Dominant Side. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed a brief interview for mental status could not be conducted, the resident was rarely/never understood, and cognitive skills for daily decision making were severely impaired. Resident #94 was dependent upon staff for toileting, bathing, dressing, hygiene, and transfers. Review of the Nurse's Note for Resident #94 dated 7/13/2025 at 10:56 AM, revealed .CNA [Certified Nurse Assistant] came up to the nurse station and stated Resident [#94] just almost slid out of her wheelchair but [CNA B] was able to reposition resident and wheelchair before [Resident #94] slid out completely. Review of the Nurse's Note for Resident #94 dated 7/14/2025 at 1:07 AM, revealed .Staff reported to this nurse [Licensed Practical Nurse (LPN) D] that resident's right arm was discolored/bruised from elbow to wrist. Upon assessment dark red discoloration noted on resident's forearm measuring 24 cm [centimeters] in length by 7 cm in width. Resident denies complaint of pain or discomfort concerning affected area.[Medical Director] notified. No new orders. Resident suffers from aphasia and was not able to communicate how injury may have occurred. Previous shift had already left for evening. Staff instructed to use caution when repositioning resident. The facility was unable to provide an assessment or any other documentation regarding the incident where Resident #94's arm was lodged in the wheelchair during the dayshift on 7/13/2025 or during the evening shift regarding the bruising on the resident's right arm that was found approximately 7:20 PM until 7/14/2025 at 1:07 AM. Review of the undated and signed Employee Investigation Interview Form signed by CNA B revealed, .Date/time of incident 7-13-25 [7/13/2025].[Resident #94] was sliding out of her wheelchair her bedside table was still in front of her .her stroke arm was not in normal position . Review of the undated and signed Employee Investigation Interview Form signed by CNA E revealed, .Date/time of incident 7-13-25 [7/13/2025] 7:20 pm [PM].[Resident #94].in bed.came in Sunday at 7:00 PM, Check resident at 7:20 PM notice large bruise on Right arm, had not Did [done] any care at that time, notified the nurse. Review of the Nurse Practitioner (NP) Note dated 7/14/2025 at 3:25 PM, revealed .Patient [Resident #94] complaints of spontaneous ecchymoses [bruising]. This has been noted for one to two days.bruising is on her right upper arm. She slid down in chair this weekend.orders given for right humerus x-ray. Review of the Nurse's Note for Resident #94 dated 7/14/2025 at 4:56 PM, revealed .[NP] in facility on this date for visit with resident regarding follow up on bruising to right upper arm.orders as follows obtained X-ray of right humerus. Review of the Radiology Results Report for Resident #94 dated 7/15/2025 at 9:16 AM, revealed HUMERUS.Acute appearing fracture of the surgical neck as noted. Review of the Nurse's Note for Resident #94 dated 7/15/2025 at 12:58 PM, revealed .[NP] reviewed right humerus x-ray results obtained on 7/15/25 [2025]. New orders.Transfer to [named hospital] on this date for possible surgical neck fracture.Bruising remains to right upper arm related to incident of sliding down in chair over the weekend. Review of the (Named Hospital) Emergency Department (ED) Triage Notes dated 7/15/2025, revealed .Patient [Resident #94] presents.from [Named nursing home] for right arm bruising and humoral fracture. Staff advised EMS [Emergency Medical Service] that they noticed the bruising yesterday and performed an X-ray which resulted .with noted fracture. Staff advised that they are unsure how the patient sustained this injury as patient is bed bound and paralyzed on the right side-right also severely contracted at baseline. Review of the signed witness statement by CNA B dated 7/15/2025, revealed .resident [#94] was sliding out of her wheelchair. she had her contracted arm in the opening of the wheelchair by [the] armrest. with her feet on the wheels of bedside table, [her] left arm was extended cross [across] her bed rail.we got her back into the wheelchair.Brought resident out to the charge nurse and reported what happened, left resident [#94] at nurse station . During a telephone interview on 8/12/2025 at 2:18 PM, Licensed Practical Nurse (LPN) C stated she was told by CNA B, on 7/13/2025, at approximately 11:00 AM, that Resident #94 had slid down in the wheelchair. LPN C confirmed she failed to assess the resident, failed to complete an incident report, failed to report the incident to administration and the oncoming staff, and failed to obtain witness statements. During a telephone interview on 8/12/2025 at 2:51 PM, CNA B told this surveyor that Resident #94 was found during the morning of 7/13/2025 with her contracted right arm lodged in the opening under the armrest of the wheelchair. CNA B confirmed she did not write a witness statement on the day of the incident. During an interview on 8/13/2025 at 8:16 AM, the Regional Nurse Consultant acknowledged that the management staff were not notified of the bruise on Resident #94's forearm until 7/14/2025. The Regional Nurse Consultant stated the nurse should have reported the bruises to the Director of Nursing (DON) when it was found on 7/13/2025 at 7:20 PM, as an injury of unknown origin. The Regional Nurse Consultant stated an injury of unknown origin should be reported to the DON and the Administrator at the time it was discovered, it should be reported to the State Survey Agency when it was discovered. The Regional Nurse Consultant agreed that Resident #94 should have been assessed, the incident documented, and an incident report completed when the resident was found with her right arm ledged in the opening under the armrest of the wheelchair. During a telephone interview on 8/13/2025 at 9:25 AM, LPN D confirmed he failed to immediately notify the provider and the DON when the bruises were found. During a telephone interview on 8/14/2025at 12:06 PM, CNA E stated on 7/13/2025 at approximately 7:20 PM, she observed a purple-colored bruise on Resident #94's right forearm and upper right arm. During a telephone interview on 8/14/2025 at 3:35 PM, the NP agreed that when staff observe bruising, they should report their findings. The NP was asked do you know what caused the bruise (on Resident #94's arm). The NP stated .we had discussed [Resident #94] had slid down in wheelchair. The NP confirmed she was not notified until 7/14/2025 of the bruising found on 7/13/2025. The facility failed to complete an incident report, failed to report the injury to management staff and the provider when the injury was found on 7/13/2025 at approximately 7:20 PM, and failed to complete a thorough investigation of Resident #94's fractured humerus.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 1 Licensed Practical Nurse (LPN R) failed to sanitize her stethoscope, failed to follow Enhanced Barrier Precautions during medication administration, when 2 of 2 Certified Nursing Assistants (CNA P and CNA Q) failed to follow Enhanced Barrier Precautions (EBP) during incontinence care, when the facility failed to ensure resident care items and equipment were labeled, contained and properly stored in resident shared bathrooms, and when 1 of 20 Certified Nursing Assistant (CNA E) directly touched residents food with her bare hands and failed to use proper hand hygiene after touching items in residents rooms during dining. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, revealed .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high contact .activities .include .device care or use .feeding tube .any skin opening requiring a dressing .indwelling medical devices . Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 10/2023, revealed .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Indications for Hand Hygiene .after touching the resident's environment .immediately after glove removal .Single-use disposable gloves should be used .when anticipating contact with blood or body fluids .when in contact with a resident, or equipment or environment of a resident, who is on contact precautions .The use of gloves does not replace hand washing/hand hygiene . 2. Review of the medical record revealed Resident #372 was admitted to the facility on [DATE] with diagnoses of Dysphagia and Gastrostomy Status. Resident was placed in Enhanced Barrier Precaution at that time. Review of the Physician's Orders dated 6/17/2024 revealed that Enhanced Barrier Precautions were put into place for Resident #372. Observation in the resident's room on 6/20/2024 at 1:35 PM, revealed LPN R failed to wear a gown when disconnecting Resident #372's enteral feeding tube from the PEG Percutaneous Endoscopic Gastrostomy) tube (a tube that is inserted into the stomach to allow you to receive nutrition). LPN R also failed to sanitize the stethoscope used to check placement of the PEG tube before exiting the room. During an interview on 6/20/2024 at 9:14 AM, the DON confirmed staff should wear Personal Protection Equipment (PPE) when entering a room where EBP should be used. Review of the medical record revealed Resident #26 admitted on [DATE] with diagnoses of Anxiety, Dementia, Peripheral Vascular Disease, and Pressure Ulcers. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #26 had a BIMS score of 15, indicating intact cognition and was coded for having a pressure ulcer. Review of the facility's Order Listing Report revealed Resident #26 was on enhanced barrier precautions due to a venous ulcer dated 6/17/2024. Observation in Resident #26's room on 6/17/2024 at 3:52 PM, revealed CNA P was providing incontinent care and did not wear proper PPE (Personal Protective Equipment) for Enhanced Barrier Precautions. CNA P then removed gloves, left resident's room to get assistance, did not perform hand hygiene. CNA P and CNA Q entered Resident #26's room, put on gloves without performing hand hygiene, and performed incontinent care without the proper PPE's. During an interview on 6/20/2024 at 4:14 PM, the Director of Nursing (DON) confirmed that staff should wear correct PPE for EBP when providing incontinent care which consists of gloves and a gown. 3. Review of the medical record revealed Resident #32 was admitted to the facility into room [ROOM NUMBER] B on 4/22/2024 with diagnoses of Fracture of Sacrum, Fracture of Right Pubis, Repeated Falls, Pain, and Atrial Fibrillation. Review of the admission MDS dated [DATE] revealed Resident #32 had a BIMs of 11, which indicated the resident was moderately cognitively impaired, requires assistance from staff for toileting and personal hygiene, and incontinent of both bowel and bladder. Review of the Care Plan dated 5/10/2024 revealed, .ADL limitations .Toileting .Requires dependent assistance . Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] into room [ROOM NUMBER] B with diagnoses of Osteoarthritis, Pain Left and Right Shoulders, Muscle Weakness, and Need for Assistance with Personal Care. Review of the quarterly MDS dated [DATE] revealed Resident #57 had a BIMs of 13, which indicated the resident was cognitively intact, required moderate assistance from staff for ADLs, and incontinent of both bowel and bladder. Review of the Care Plan dated 2/20/2024 revealed, .ADL limitations .Toileting .Requires dependent assistance . Review of the medical record revealed Resident #175 was admitted to the facility on [DATE] with diagnoses of Nontraumatic Intracerebral Hemorrhage, Nontraumatic Chronic Subdural Hemorrhage, Dementia, Epilepsy, Dysphagia, and Urinary Tract Infection. Review of the admission MDS dated [DATE] revealed Resident #175 had a BIMs of 4, which indicated the resident was severely cognitively impaired, moderately to dependent on staff for ADLs, incontinent of both bowel and bladder. Review of the Care Plan dated 6/18/2024 revealed, .ADL limitations .Incontinence .Infection risk r/t [related] history of Sepsis/UTI [urinary tract infection] . Observation in the shared bathroom of Resident #32, #57, #175 on 6/17/2024 at 9:40 AM, 11:33 AM, and 2:46 PM, and on 6/18/2024 at 8:10 AM, revealed 1 gray bed pan, 1 plastic urinal, 1 plastic white graduate hat dispenser on the back of the toilet, unlabeled and uncontained. 4. Observation in the shared bathroom for Rooms 205 and room [ROOM NUMBER] on 6/17/24 at 9:47 AM, at 10:47AM, and at 4:00 PM, revealed 1 pink denture cup, 1 green denture cup on top of the bathroom vanity, unlabeled and uncontained, 2 gray bedpans sitting on back of the toilet, unlabeled and uncontained, and 1 urinal on the toilet side rails, unlabeled and uncontained. During observation and interview in shared bathroom for rooms [ROOM NUMBERS] on 6/18/24 at 2:41 PM, revealed, 2 gray bed pans sitting on the back of the toilet, unlabeled and uncontained, 1 urinal sitting on the back of the toilet, unlabeled and uncontained, and 1 pink and 1 green denture cup sitting on top of the bathroom vanity, unlabeled and uncontained. LPN R confirmed that resident's bed pans and urinals should be labeled and in plastic bags and stored in the resident's drawer in the bedside table. LPN R confirmed that resident's denture cups should have the resident's names on them and should be stored in the resident's table or bedside drawer. 5. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Psychotic Disturbances, Difficulty Walking, Insomnia, Diabetes, Hemiplegia and Hemiparesis, and Overactive Bladder. Review of the quarterly MDS dated [DATE] revealed Resident #33 had a BIMs of 3, which indicated the resident was severely cognitively impaired, upper and lower extremity range of motion limitations, dependent on staff for toileting, and incontinent of both bowel and bladder. Review of the Care Plan dated 3/12/2024 revealed, .ADL limitations .Requires mobility-substantial/max assistance .does not get up to bathroom at night .Total incontinence . Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of Unsteadiness on Feet, Contracture Left Wrist and Hand, History of Falling, Dementia, Repeated Falls, Alzheimer's Disease, Lack of Coordination, Atrial Fibrillation, and Difficulty Walking. Review of the quarterly MDS dated [DATE] revealed Resident #52 had a BIMs of 3, which indicated the resident was severely cognitively impaired, required maximal assistance with toileting, incontinent of both bowel and bladder, and diuretic medication use. Review of the Care Plan dated 1/18/2024 revealed, .ADL limitations .requires assistance with ADLs .Requires mobility assistance with urinal. Resident does not get up to the bathroom at night .Incontinence .Offer toileting assistance with bedpan, urinal, or commode use .Infection .risk for r/t incontinence .Linezolid .twice daily .x 5 days .or Urinary Tract Infection . Observation in the shared bathroom for Resident #33 and Resident #52 on 6/17/24 at 10:01 AM, 3;15 PM, and 4:00 PM, and on 6/18/2024 at 8:19 AM, revealed 1urinal, and 1 handled graduate dispenser on the back of the toilet, unlabeled and uncontained. During observation and interview in the shared bathroom for Resident # 33 and Resident #52 6/18/24 at 3:45 PM, revealed CNA D, placing a urinal in a plastic bag and was asked how urinals and bed pans should be stored. CNA D confirmed that urinals should be stored in plastic bags with the resident's name on them. During an interview on 6/20/24 at 1:00 PM, the DON confirmed that all urinals, bedpans, and graduate dispensers should be cleaned and dried after use, placed in a plastic and stored in the bottom drawer of the resident's nightstand. The DON confirmed that they should be labeled with the resident's name if stored in a shared bathroom. 6. Observation in the East Hall during dining on 6/17/24 at 11:08 AM, revealed CNA E, sanitized her hands, removed a tray from the meal and entered Resident #20's room. CNA E placed the tray on the over the bed table, removed the bread from the plastic package with her bare hands and placed it on the resident's plate, set the meal tray up and exited the room. CNA E failed to use hand sanitizer or use hand hygiene before picking up the bread with her bare hands. Observation in the East Hall during dining on 6/17/2024 at approximately 11:10 AM, revealed CNA E knocked and entered Resident #51's room, adjusted the head of the bed with the hand-held crank, donned a pair of clean gloves, adjusted the resident in bed, removed her gloves and set up the meal tray. CNA E removed the bread from the plastic package with her bare hands and placed it on the resident's plate, picked the bread back up with her bare hands and moved to the other side of the plate, CNA E exited the room and returned to the meal cart. CNA E failed to use sanitizer or hand hygiene after touching items in the resident room and before picking up the resident's bread with her bare hands. Observation in the East Hall during dining on 6/17/2024 at approximately 11:15 AM, CNA E sanitized her hands, entered Resident #6's room, picked up the call light off the floor and exited the room, returned to the meal cart and removed a tray. CNA E failed to sanitize or use hand hygiene after touching resident items and before returning to the meal cart. CNA E re-entered Resident #6's room, placed the tray on the over the bed table, adjusted the bed with the hand-held control, adjusted the height of the over the bed table, removed the lid from the meal tray, removed the bread from the plastic package with her bare hands. CNA E failed to sanitize or use hand hygiene after touching resident items and before picking up the bread with her bare hands. During an interview on 6/20/24 at 1:00 PM, the DON confirmed that staff should not touch resident's food with their bare hands and personal care items such as urinals, bed pans, graduate dispensers, and hat dispensers should be labeled with the resident's name, covered, and stored in the bottom drawer in the resident's room but can be stored in a shared bathroom if labeled with the resident's name and covered properly.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during dining when 6 of 18 staff members Certified Nursing Assistant (CNA) C, CNA E, and CNA F, Hydration Aides K and Hydration Aide L, Licensed Practical Nurse (LPN) M, and Activities Tech O, failed to knock and/or announce themselves before entering a resident's room and failed to use courtesy titles when addressing residents and referring to residents. The findings include: 1. Review of the facility's policy titled, Dignity, revised 2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Staff are expected to knock and request permission before entering residents' rooms. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . 2. Observation in the East Hall during dining on 6/17/24 at 11:08 AM, revealed CNA E, sanitized her hands, removed a tray from the meal cart, entered Resident #20's room, placed the tray on the over the bed table and began to set up the meal tray. CNA E failed to knock and/or announce herself before entering the resident's room. Observation in the East hall during dining on 6/17/2024 at approximately 11:15 AM, CNA E sanitized her hands, entered Resident #6's room, picked up the call light off of the floor, returned to the meal cart and removed a tray, entered Resident #6's room, placed the tray on the over the bed table and began to set up the meal tray. CNA E failed to knock and/or announce herself before entering the resident's room. 3. Observation in the East back hall during dining on 6/18/24 at 5:12 PM, revealed Hydration Aide K and Hydration Aide L removed a tray from the meal cart, entered Resident #11 and Resident #55's room and failed to knock and/or announce themselves. Observation in the East Hall during dining on 6/18/2024 at 5:20 PM, revealed Hydration Aide K, sanitized her hands, removed a tray from the meal cart, entered Resident #20's room, placed the tray on the over the bed table, set up the meal tray, exited the room and returned to the meal cart. Hydration K failed to knock and/or announce herself before entering the resident's room. 4. Observation in the East Hall during dining on 6/18/2024 at approximately 5:22 PM, revealed CNA C, removed a tray from the meal cart, entered Resident #57's room, placed the tray on the over the bed table, set up the meal tray and exited the resident's room. CNA C failed to knock and/or announce herself before entering the resident's room. 5. Observation in the East back hall during dining on 6/18/2024 at approximately 5:25 PM, revealed CNA F in a loud voice while walking down the hall stated, Who down here got to be fed . LPN A stated, [Named Resident #222 and Named Resident #175], who is feeding [Resident #5]. CNA F stated, I am feeding [Named Resident #5]. Activities Tech stated, [Named Resident #5] already been fed. 6. Observation in the East back hall during dining on 6/18/2024 at approximately 5:27 PM, revealed Activities Tech O removed a tray from the meal cart and entered Resident #222's room, placed the tray on the over the bed table, set up the meal tray and began to assist Resident #222 with her lunch meal. The Activities Tech failed to knock and/or announce herself before entering the resident's room. During an interview on 6/20/24 at 1:00 PM, the Director of Nursing (DON) confirmed that staff should knock and/or announce themselves before entering a resident's room to provide care or serve a meal. The DON confirmed that staff should address residents with courtesy titles or what is preferred and care planned, using the residents first or last name adding Mr. and Mrs. and that residents should not be referred to as feeders.

Based on medical record review, observation, and interview the facility failed to follow physician's preventive measures order for wounds for 1 of 16 (Resident #43) sampled residents reviewed for physician orders. The findings include: Review of the medical record revealed Resident #43 was admitted on [DATE], with diagnoses including Alzheimer's, Diabetes, Stage 3 Pressure Ulcer of Sacral, Stage 4 Pressure Ulcer Left Lateral Leg, and Unstageable Left Heel. Review of the Care Plan dated 1/20/2024 revealed .returned from recent hospital stay with a stage II to sacrum .Implement pressure ulcer treatment per MD order .03/26/24 [3/26/2024]: Stage III to sacrum resolved as of this date .Stage III to sacrum reopened as of this date. To be treated per MD orders . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #43 was moderately impaired for daily decision making, and had 1 stage 3 pressure ulcer and 3 deep tissue injury. Review of the Physician's Orders dated 3/28/2024, revealed .apply calmoseptine [an ointment and moisture barrier that protects and helps heal skin irritations .] to sacrum .bilateral buttocks .every shift for preventative measures . Review of the April 2024 Treatment Administration Record (TAR) revealed .apply calmoseptine [an ointment and moisture barrier that protects and helps heal skin irritations .] to sacrum .bilateral buttocks .every shift for preventative measures .Start Date 03/27/2024 . The treatment to the sacrum wound was not signed as being administered on 4/1/2024, 4/6/2024, 4/7/2024, 4/10/2024, 4/15/2024, 4/17/2024, 4/19/2024, 4/26/2024, and 4/29/2024. Review of the May 2024 Treatment Administration Record (TAR) revealed .apply calmoseptine to sacrum .bilateral buttocks .every shift for preventative measures .Start Date 03/27/2024 . The treatment to the sacrum wound was not signed as being administered on 5/13/2024, 5/14/2024, 5/15/2024, 5/20/2024, 5/21/2024, 5/22/2024, 5/24/2024, and 5/31/2024. Observation in Resident #43's room on 6/20/2024 at 7:20 AM, revealed resident dressed lying in the bed, eating a jelly and biscuit. During an interview on 6/21/2024 at 10:37 AM, the Director of Nursing (DON) was shown the TAR for April and MAY and confirmed there should not be empty blanks on the TAR and the Physician orders were not followed.

Based on policy review, medical record review, and interview, the facility failed to ensure the residents oxygen tubing and humidifier bottle was dated for 2 of 4 (Resident #54 and #224) reviewed for oxygen. The findings include: 1. Review of the facility's policy titled, Oxygen Administration, dated 4/2014, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration .Before administering oxygen, and while the resident is receiving oxygen therapy .Oxygen tubing should be replaced weekly as well as humidifier bottles .should be labeled with a resident identifier and dated . 2. Review of the medical record revealed #54 was admitted on [DATE], with diagnoses including Parkinson's, Heart Failure, and Chronic Obstructive Pulmonary Disease Review of the annual Minimum Data Set (MDS) dated [DATE], revealed #54 had a Brief Interview for Mental Score (BIMS) score of 13, indicating the resident had intact cognition, and was not coded for oxygen. Review of the care plan dated 4/8/2024, revealed Resident #54 was care planned for oxygen use as needed. Review of the physician's order dated 6/4/2024, revealed Resident #54 had an order for oxygen at 2-3 liters per minute bi-nasal canula as needed. Observations in the resident's room on 6/17/2024 at 3:21 PM and on 6/18/2024 at 8:58 AM, 10:43 AM, and 3:34 PM, revealed Resident #54's oxygen tubing had no date on it and the humidifier bottle was dated 6/7/2024. 3. Review of the medical record revealed Resident #224 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #224 had a BIMS score of 13, indicating the resident had intact cognition and had oxygen. Review of the physician order dated 6/4/2024, revealed Resident #224 had an order for oxygen bi-nasal cannula at 2 liter per minute for oxygen saturation less than 92 precent as needed. Observations in the resident's room [ROOM NUMBER]/17/2024 at 3:34 PM and 6/18/2024 at 3:17 PM and 3:32 PM, revealed Resident #224's oxygen tubing and humidifier bottle had no date on them. During an interview in the resident's room on 6/18/2024 at 3:17 PM, Resident #224 confirmed the use of oxygen as needed. Resident #224 stated, .They only put it (Oxygen) on me when they check my vitals, if the oxygen is low. They put it on me this morning . 4. During an interview on 6/18/24 at 3:26 PM, the Director of Nurses (DON) asked when the oxygen tubing and the humidifier bottle should be changed. The DON stated, .the tubing and humidifier bottle should be dated and changed every 7 days . During an observation and interview in the resident's room on 6/18/2024 at 3:32 PM, the DON confirmed Resident #224's oxygen tubing and humidifier bottle was not dated. During an interview on 6/18/2024 at 3:34 PM, the DON confirmed Resident #54's oxygen tubing was not dated and the humidifier bottle was dated 6/7/2024. The Director of Nurses confirmed Resident #54's oxygen tubing should have a date on it. The DON stated, .it is our responsibility for replacing and making sure the tubing and humidifier is changed every 7 days and dated the tubing should have a date and the humidifier bottle should have been changed by the 6/14/2024.

Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 4 of 60 (Resident #1, #32, #39, and #173) resident rooms observed. The findings include: 1. Review of the facility's policy titled, Cleaning and Disinfection of Environmental Surfaces, Resident-Care Items, Equipment and Other Items, Revised 8/2010, revealed, .Walls, blinds, and window curtains in resident areas shall be cleaned when these surfaces are visibly contaminated or soiled . Review of the facility's Housekeeping and Laundry Service Cleaning Schedule, revealed, .Shift .First .Ceiling .Vents, Light Fixtures, Cubicle Curtains/Tracks .Cleaning Schedule .Weekly . 2. Observation in Resident #32's room on 6/17/24 at 9:40 AM, 11:33 AM, at 2:46 PM, and on 6/18/2024 at 8:10 AM, revealed a dark brown stain at the bottom of the middle divider privacy curtain that separates the A bed from the B bed. 3. Observation in Resident #39's on 6/17/24 at 9:52 AM, 2:43 PM, 3:47 PM, and on 6/18/2024 at 8:49 AM, revealed dark brown stains at various places on the middle divider privacy curtain that separates the A bed from the B bed. 4. Observation in Resident #1 and Resident #173's room on 6/17/24 at 9:55 AM, 4:45 PM, revealed dark brown and gray spots stains on the divider privacy curtain that separates the A bed from the B bed and on the privacy curtain on the B side of the room near the window. During observation and interview in Resident #1 and Resident #173's room on 6/18/24 at 2:45 PM, revealed dark brown and gray stains on the divider privacy curtain that separates the A bed from the B bed. The Housekeeper was asked was asked how often privacy curtains are cleaned. The Housekeeper confirmed she has never taken them down and she was unaware of who inspects them and takes them down to clean. During observation and interview in Resident 173's room on 6/18/24 at 2:55 PM, the Housekeeping and Laundry Supervisor was shown the dark brown stains on the privacy curtain and was asked, how often are the privacy curtains inspected to ensure they are clean and are in good repair. The HK/Laundry Supervisor stated, .at least every other day I check them myself to make sure they are clean .I go around and I check them and if I find something then I go get the housekeeper to have them taken down and replaced or washed. The HK/Laundry Supervisor was asked when the last time was they were checked for cleanliness. The HK/Laundry Supervisor stated, .Friday and I take them down once a month and wash them .I am going to take them down .and wash these .

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 26 (Certified Nursing Assistant (CNA) #1 and CNA #9, Licensed Practical Nurse (LPN) #1, and the Activities Director) staff members observed during dining failed to knock, announce or introduce themselves when entering a resident's room and failed to use courtesy titles to address residents. The findings include: 1. Review of the facility's policy titled Dignity, revised 2/2021, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life and feelings of self-worth and self-esteem .The facility culture supports dignity and respect for residents .Residents are treated with dignity and respect at all times .Staff are expected to knock and request permission before entering resident's rooms .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice .not labeling . Review of the facility's .Resident Rights Policy, dated 11/2016, revealed, .Rights of residents for the protection and preservation of dignity, individuality .The resident has the right to be treated with respect and dignity . Review of the facility's policy titled, Assistance with Meals, revised 8/2009, revealed, .Residents who cannot feed themselves will be fed with attention to .comfort and dignity .Not standing over residents while assisting them with meals . 2. Observation during dining in the East Hall on 2/27/2023 beginning at 11:15 AM, revealed the following: a. CNA #1 entered Resident #63's room and stated, Hey Sugar, you want your lunch. CNA #1 failed to knock, announce herself, or ask permission to enter the room and failed to use a courtesy title when addressing the resident. b. CNA #1 removed a tray from the meal cart, entered Resident #44's room, and placed the meal tray on the over-the-bed table. CNA #1 failed to knock, announce herself, or ask permission to enter the resident's room. c. CNA #1 removed a tray from the meal cart, entered Resident #22's room, and placed the meal tray on the over-the-bed table. CNA #1 failed to knock, announce herself, or ask permission to enter the room. d. CNA #1 removed a tray from the meal cart and entered Resident #7's room. CNA #1 failed to knock, announce herself, or ask for permission to enter the room. e. LPN #1 entered Resident #52's room and stated, Well girlfriend the top's not working with me. LPN #1 failed to use a courtesy title when addressing the resident. f. LPN #1 stood while assisting Resident #38 with her meal. LPN #1 failed to be at eye level while assisting the resident. g. The Activities Director removed a tray from the meal cart, entered Resident #63's room and asked, Hey honey, are you ready to eat lunch? The Activities Director failed to use a courtesy title when addressing Resident #63. 3. Observation during dining in the 200 Hall on 2/28/2023 at 5:29 PM, revealed CNA #9 entered Resident #42's room. CNA #9 failed to knock, announce herself, or ask for permission to enter the resident's room. 4. During an interview on 3/2/2023 at 9:18 AM, the Director of Nurses (DON) confirmed staff should not stand over a resident while assisting with their meals, and staff should be at eye level.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 1 (Resident #41) was free from the use of restraints. The findings include: Review of the facility's policy titled, Use of Restraints, dated 2008, revealed, .If the resident cannot remove the device in the same manner in which the staff applied it .that device is considered a restraint .Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination . Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Heart Failure, and Depression. Review of the Care Plan revealed Resident #41 was not care planned for the use of a merri-walker (a type of adaptive equipment that is a combination of a wheelchair and a walker and has a safety belt and latch lock). Review of a Physician's Order dated 5/27/2022 revealed, .RESIDENT MAY BE UP AD LIB (as much and as often as desired) IN MERRI-WALKER DURING PERIODS OF RESTLESSNESS TO ALLOW SAFE AMBULATION AND REST PERIODS . Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident was assessed with a Brief Interview for Mental Status score of 3, indicating this resident is severely cognitively impaired, with inattention and disorganized thinking and required extensive assistance with activities of daily living. Observation at the West Nurses station on 2/27/23 at 3:55 PM and 4:36 PM, and 3/1/2023 at 1:37 PM, revealed Resident #41 up ambulating in the merri-walker. Observation in the East Hall on 2/28/23 at 4:47 PM, revealed Resident #41 in the merri-walker with staff assisting the resident back to her room. Observation in the East Hall on 3/1/23 at 2:39 PM, revealed, the Assistant Director of Nursing (ADON) and the Restorative Nurse assisted Resident #41 into a resident room. Observation of the merri-walker revealed the merri-walker had a harness belt (device to lock the belt on the merri-walker into place) and a cross bar with a pull pin release. The ADON instructed Resident #41 on 2 separate occasions to remove the harness buckle with Resident #41 unable to follow the command. The Restorative Nurse asked Resident #41 to remove the harness belt, and Resident #41 was unable to follow the command. Resident #41 was speaking incoherently and rubbed her fingers over the harness buckle but was not able to open or release the buckle. During an interview on 3/1/23 at 1:17 PM, the Physical Therapist (PT) was asked if therapy attempted to use any other device for ambulation or mobility other than the merri-walker. The PT confirmed that she had not assessed the resident for any other device for mobility. During an interview on 3/1/23 at 1:22 PM, the Restorative Nurse was asked if Resident #41 could release the harness belt or the pull pin and raise the bar on command to exit the merri-walker. The Restorative Nurse stated, No, not mentally-wise .she would not be able to . The Restorative Nurse was asked if the resident could release the bar or get out of the merri-walker when commanded by staff. The Restorative Nurse confirmed Resident #41 could not release the bar or get out of the merri-walker on command. The Restorative Nurse confirmed no reduction had been attempted for the use of the merri-walker. During an interview on 3/1/23 at 1:31 PM, the Nursing Assistant (NA) confirmed Resident #41 required total care with her activities of daily living skills. The NA was asked if the resident could release the harness belt and pull pin and raise the bar if asked to on command. The NA stated, .no we have to do everything for her, she can't do that by herself . During an interview on 3/1/2023 at 5:02 PM, the Administrator was asked if the facility attempted to use any other device for mobility. The Administrator stated, .No . Review of Resident #41's medical record revealed the facility failed to assess the resident for the use of a restraint and failed to conduct restraint reductions for Resident #41.

Based on policy review, medical record review, observation, and interview, the facility failed to monitor oxygen administration for 1 of 2 residents (Resident #51) reviewed for respiratory services. The findings include: Review of the facility's policy titled, Oxygen Administration, dated 10/2010, revealed, .Verify that there is a physician's order for this procedure .start the flow of oxygen at the rate prescribed by the physician . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety and Pain. Review of the Progress Notes dated 2/24/2023 revealed, .Respiratory Note: .3Lpm [3 liters per minute] BNC [by nasal cannula] . Review of the Physician's Order dated 2/28/2023, revealed, .CONTINUOUS OXYGEN AT 2 L/MIN [2 liters per minute] .NASAL CANNULA TO KEEP SATS [oxygen saturations] > [greater than] 92 % [percent] every shift for SHORTNESS OF BREATH . Review of the medical record revealed Resident #51 did not have a physician's order for oxygen until 2/28/2023. Observations in the resident's room on 2/27/2023 at 2:46 PM, and 2/28/2023 at 8:59 AM, revealed Resident #51's oxygen flowing at a rate of 4 liters per minute via the oxygen concentrator machine. During an interview on 3/1/2023 at 11:12 AM, the Director of Nursing was asked if there should be a physician's order written when oxygen was in use. The DON stated, Yes.

Based on policy review, observation, and interview the facility failed to ensure medications were properly stored and secured when opened controlled medications that are subject to abuse were found outside of separately locked, permanently affixed compartments for storage in 2 of 8 (East Hall Medication Storage Room and West Hall Medication Storage Room) medication storage areas. The findings include: 1. Review of the facility's policy titled, Storage of Medications, dated 9/2019, revealed, .The facility shall store all drugs and biologicals in a safe secure and orderly manner .Compartments (including drawers, cabinets, rooms .) containing drugs .shall be locked when not in use . 2. Observation in the East Hall Medication Storage Room on 2/28/2023 at 3:41 PM, revealed the following controlled medications that were not in separately locked, permanently affixed compartments: a. Lorazepam (a controlled medication used for the treatment of anxiety) 0.5 milligrams (mg) 94 tablets b. Alprazolam (a controlled medication used for the treatment of anxiety) 0.25 mg 30 tablets c. Hydrocodone-acetaminophen (a controlled pain medication) 5-325 mg 38 tablets During an interview in the East Hall Medication Storage Room on 2/28/2023 at 4:40 PM, Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1 and LPN #2 confirmed that storage of controlled medications should be secured. 3. Observation in the West Hall Medication Storage Room on 2/28/2023 at 5:45 PM, revealed the following controlled medications: a. Lorazepam 0.5 mg 90 tablets b. Clonazepam (a controlled medication used for the treatment of anxiety) 0.5 mg 30 tablets c. Alprazolam 0.5 mg 30 tablets During an interview on 2/28/2023 at 5:52 PM, LPN #3 confirmed all medications should be locked and secured. 4. During an interview on 3/2/2023 at 8:46 AM, the Director of Nursing (DON) was asked how controlled medications should be stored. The DON stated, Narcotics [controlled medications] should be stored behind a double lock at all times .