Every finding on record at Belterra Health & Rehab

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to four of eight residents (Residents #56, #83, #109, and #120) reviewed for baseline care plan. 1. The facility failed to ensure Residents #56 had a baseline care plan after admission to the facility on [DATE]. 2. The facility failed to ensure Residents #83 had a baseline care plan after admission to the facility on [DATE]. 3. The facility failed to ensure Residents #109 had a baseline care plan after admission to the facility on [DATE]. 4. The facility failed to ensure Residents #120 had a baseline care plan after admission to the facility on [DATE]. These failures could place the residents at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening conditions.Findings included: 1. Record review of Resident #56's Face Sheet, dated 04/23/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Upon admission, the resident was diagnosed with respiratory failure with hypoxia (insufficient amount of oxygen in the body), congestive heart failure (condition in which the heart cannot pump blood well enough to meet the body's needs), epilepsy (a medical condition characterized by recurring seizures), edema (swelling), shortness of breath, hypertension (high blood pressure), atrial fibrillation (an irregular, rapid heartbeat), benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged and not cancerous), dementia (a condition characterized by loss of memory and ability to reason), anxiety (intense or excessive fear or worry), and depression (persistent feeling of sadness or loss of interest). Record review of Resident #56's Comprehensive MDS Assessment, dated 04/07/2026, reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy and had respiratory failure with hypoxia, congestive heart failure, epilepsy, edema, shortness of breath, hypertension, atrial fibrillation, benign prostatic hyperplasia, dementia, anxiety, and depression. Record review on 04/23/2026 of Resident #56's Baseline Care Plan reflected that the resident did not have a care plan after forty-eight hours to address his use of oxygen. The resident's baseline care plan did not include the minimum healthcare information necessary to properly care for the resident immediately upon admission. The plan did not address any resident-specific health issues such as respiratory failure with hypoxia, congestive heart failure, epilepsy, edema, shortness of breath, hypertension, atrial fibrillation, benign prostatic hyperplasia, dementia, anxiety, and depression. The plan did not reflect any goals and interventions to address his current needs. Record review of Resident #56's Progress Notes, dated 04/05/2026, reflected O2 96 % - 4/5/2026 21:29 Method: Oxygen via Nasal Cannula. Record review of Resident #56's Physician Order, dated, 04/05/2026, reflected Administer continuous oxygen at [2 LPM] Liters per [PER NASAL CANNULA OR MASK TYPE]; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SO WHILE LAYING FLAT every shift for oxygen related to SHORTNESS OF BREATH. During an observation and interview on 04/21/2026 at 9:21 a.m. revealed Resident #56 was sitting in his wheelchair, awake. It was observed that he was using oxygen via nasal cannula. The resident said he was using oxygen since he was admitted to the facility. 2. Record review of Resident #83's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Upon admission, the resident was diagnosed with dysphagia (difficulty in swallowing) and gastro-esophageal reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), diabetes mellitus (high blood sugar), gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support), hypertension (high blood pressure), myocardial infarction (heart attack), constipation. Record review of Resident #83's Comprehensive MDS Assessment, dated 04/07/2026, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS 09. The Comprehensive MDS Assessment indicated the resident had a feeding tube, dysphagia, gastro-esophageal reflux, diabetes mellitus, hypertension, myocardial infarction, and constipation. Record review on 04/22/2026 of Resident #83's Baseline Care Plan, dated 04/06/2026, reflected that the resident was only care planned for his dependency on the staff. The resident did not have a care plan for his feeding tube, diabetes mellitus, hypertension, myocardial infarction, and constipation. The resident's baseline care plan did not include the minimum healthcare information necessary to properly care for the resident immediately upon admission. The plan did not reflect any goals and interventions to address his current needs. Record review of Resident #83's Physician Order, dated 04/03/2026, reflected Enteral Feed Order every shift Enteral: Check tube placement via residual and tube visualization before initiation of formula, medication administration, and flushing tube. Record review of Resident #83's Progress Note, dated 04/03/2026, reflected Resident arrived at the facility . G-tube patent and intact. During an observation and interview on 04/21/2026 at 12:25 p.m., revealed that Resident #83 was in his wheelchair, awake. It was observed that the resident had a g-tube to the right upper quadrant of his abdomen. He said he had the g-tube for years. 3. Record review of Resident #109's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident was diagnosed with presence of cellulitis (bacterial infection of the skin and the tissues beneath it), injury to left kidney, pain, hypertension, heart block (issue with the heartbeats). Record review of Resident #109's Comprehensive MDS Assessment, dated 04/21/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy and had cellulitis, injury to left kidney, pain, hypertension, and heart block. Record review of Resident #109's Baseline Care Plan, dated 04/18/2026, reflected that the resident was only care planned for being full code and having an ADL self-care deficit. The plan did not address the resident's use of oxygen. The resident's baseline care plan did not include the minimum healthcare information necessary to properly care for the resident immediately upon admission. The plan did not address any resident-specific health issues such as cellulitis, injury to left kidney, pain, hypertension, and heart block. The plan did not reflect any goals and interventions to address his current needs. Record review of Resident #109's Physician Order, dated 04/18/2026, reflected Oxygen: Administer continuous oxygen at [2 LPM] Liters per [PER NASAL CANNULA OR MASK TYPE]; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT every shift. Record review of Resident #109's Progress Note, dated 04/18/2026, reflected Patient admitted . on oxygen therapy 2 liter via NC.4. Record review of Resident #120's Face Sheet, dated 04/23/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident was diagnosed with diabetes mellitus, neoplasm of the digestive system, hypertension, depression, atrial fibrillation, neuromuscular dysfunction of the bladder, and retention of urine. Record review of Resident #120's Comprehensive MDS Assessment, dated 04/10/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had an ostomy, indwelling catheter, hypertension, diabetes mellitus, neoplasm (abnormal growth of tissue in the body) of the digestive system, depression (persistent feeling of sadness or loss of interest) , atrial fibrillation, neuromuscular dysfunction of the bladder (the muscles and nerves that control the bladder do not work properly due to illness), and retention of urine (a condition in which the urinary bladder does not empty completely). Record review of Resident #120's Baseline Care Plan, dated 04/09/2026, reflected the resident was not care planned for her colostomy bag (plastic pouch that collects fecal matter from the digestive tract), catheter (flexible tube inserted into the bladder to remove the urine), hypertension, diabetes mellitus, neoplasm of the digestive system. The resident's baseline care plan did not include the minimum healthcare information necessary to properly care for the resident immediately upon admission. The plan did not address any resident-specific health issues such as colostomy (surgery that creates an opening to the large intestine), indwelling catheter, hypertension, diabetes mellitus, neoplasm of the digestive system, depression, atrial fibrillation, neuromuscular dysfunction of the bladder, and retention of urine. The plan did not reflect any goals and interventions to address his current needs.Record review of Resident #120's Physician Order, dated 04/08/2026, reflected Provide colostomy care with approved cleaning agent. Record review of Resident #120's Progress Note, dated 04/08/2026, reflected patient admitted . patient with a LLQ colostomy. During an observation and interview on 04/23/2026 at 6:08 a.m., the MDS Coordinator said all the residents admitted should have a baseline care plan within 48 hours to be able to meet the immediate needs of the residents. She said Resident #109 had a baseline care plan. She opened Resident #109's profile and navigated through the resident Assessment Notes, Baseline Care Plan v 2 and said that it was the resident's Baseline Care Plan. It was observed that the Baseline Care Plan v 2 did not have any goals and interventions of the resident's oxygen use and her other co-morbidities. She said she was off the week prior and did not know who should be doing the baseline care plan. She said the plan could be done by the admitting nurse, ADON, and the DON. During an interview on 04/23/2026 at 6:26 a.m., the DON said baseline care plans were important because it would give the providers the minimum healthcare information about the residents that needed to be addressed immediately or upon admission. She said the MDS Coordinator was the one doing the baseline care plan. She said the admitting nurses do not do baseline care plans because they were avoiding too many hands handling care plans. She said with new residents, they had 48 to 72 hours to complete the baseline care plan. She said for some of the residents that were newly admitted , the base line care plans were not done because they were busy with an incident that happened to the facility. She said, maybe, she should consider allowing the admitting nurses to do the baseline care plan during admission. She said the expectation was for the residents to have a baseline care plan and said she would coordinate with the MDS Coordinator about the issue. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the expectation was for all the residents admitted had baseline care plans. She said she would coordinate with the DON and MDS Coordinator about baseline care plans. In an observation and interview on 04/23/2026 at 10:01 a.m., the DON said the Corporate Nurse said to check in the Assessment Notes for the residents' base line care plan and not the usual place where care plans were checked. She navigated on Resident #109's profile to show an example. She ended up looking at the resident's Baseline Care Plan - V 2.Record review of Residents #56, #83, #109, and #120 Baseline Care Plan - V 2 reflected that their Baseline Care Plan v 2 did not have any goals and interventions regarding the residents' immediate medical needs. It only indicated check marks of the initial assessment for the residents.Record review of the facility's policy Care Plans - Baseline 2001 MED-PASS, Inc. revised November 14, 2023 reflected Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . Policy Interpretation and Implementation . 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed withing forty-eight (48) hours of the resident's admission . 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs . 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. The Baseline Care Plan v1.1 or equivalent can be utilized for bassline care planning.

Based on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision to prevent accidents and/or hazards for 3 (Residents #68, #107, and #110) of 8 residents reviewed for supervision and accidents/hazards.1. The facility failed to ensure there were no germicidal wipes on Resident #107's side table on 04/21/2026.2. The facility failed to ensure there were no germicidal wipes on the floor, in front of Resident #110's room on 04/21/2026.3. The facility failed to ensure Resident #68 received adequate supervision allowing Resident #68 to exit the facility without the knowledge of staff on 04/13/2026 for approximately 20 minutes. Resident #68 was located at Walgreens, which is parallel to the facility approximately 528 yards from the facility. These failures could place residents at risk for injuries, decline in health, and having an environment that was free from exposure to toxic chemicals.Record review of Resident #68's face sheet dated 04/13/2026 revealed a [AGE] year-old male with an admission date of 05/06/2025 and a discharge date of 04/20/2026. Diagnosis included Unspecified Dementia (cognitive decline (memory, thinking, or behavioral issues), Major depressive disorder (persistent low mood, loss of interest in activities, and low energy lasting at least two weeks), and Type II Diabetes (a chronic condition where the body resists the effects of insulin or fails to produce enough to maintain normal glucose levels, causing high blood sugar). Record review of Resident #68's Quarterly MDS dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Review of the BIMS conducted on 04/13/2026 revealed a score of 7, indicating severe cognitive impairment. Resident #68 MDS reflected the following: he could walk 150 feet with supervision or touching assistance, he did not use a wheelchair, and he did not have a history of wandering. Record review of elopement assessments completed on the following dates: 05/06/2025, 08/06/2025, 10/30/2025 and 01/30/2026, revealed Resident #68 was not an elopement risk. Record review of Resident #68's care plans dated 04/13/2026 revealed there were no care areas regarding supervision, wandering, or elopement as Resident #68 did not have a history of trying to leave the facility. Record review of the weekly body audit conducted on 04/13/2026 at 12:45 p.m. after Resident #68 returned to the facility reflected, Intact, no skin issues. Record review of incident report dated 04/13/2026 at 12 p.m. revealed the following: It was reported that resident was sitting on a rock at [Store] on [Address] and fell backwards. Resident did not hit his head and was assisted by [Store] staff and facility was notified. Resident didn't report a fall when he returned to facility. The incident report revealed the following: Immediate Action Taken: This nurse assessed resident, no obvious injuries noted at this time. Residents deny any pain or discomfort. V/S 118/72, p80, R, 16, Temp 97.8, O2 sat 95% on room air. [Doctor], DON, Administrator, and [Family Member] aware of fall. Resident put on q15 checks, Resident will be sent out to hospital for further management. Injury Type: No injuries observed at time of incident. Mental Status: Oriented to person, place, and situation. Injuries Report Post Incident: No injuries observed post incident. Predisposing Physiological Factors: Gait imbalance and Impaired memory. Predisposing Situation Factors: Ambulating without assist. Continued review of the incident report revealed the following: Statements from relative: Family member, [Family Member] state that they were told by employee at [Store]'s that resident had entered the store, walked around it, and left the store. But while on his lunch break, the employee went outside to sit in his car and noted the resident sitting on a decorative rock. He asked the resident if he needed any help and the resident stated, I am waiting for a ride. But as employee sat in his car, he observed the resident trying to adjust his shoe and lose balance and fell off the rock backwards. The employee helped him get up, dust off, and go inside the store. The resident was able to tell him his name, that he lives at Belterra and his room [ROOM NUMBER]. The employee then called the facility to notify staff. In an interview on 04/23/2026 at 2:35 p.m., the DON stated that [Store} was about 500 yards from the facility. It was 70 degrees outside. The store was located on the corner of [Address], which is in front of the hospital. She stated the cameras were reviewed and it appeared that Resident #68 followed a group of women out of the front door who had been there providing an activity for the residents. No one was aware he was gone until the employee from [Store] called to alert the staff. Staff took the facility van and brought Resident #68 back. Resident # 68 was assessed when he returned to the facility at approximately 12 p.m. and the family requested he go to the hospital and accompanied him. A full work up was done and there were no negative findings. When he returned to the facility, the social worker assisted the family in finding a memory care unit. Resident # 68 was placed on 1:1 with a sitter until he was discharged from the facility on 04/20/2026. Record review of the 1:1 log for Resident #68 revealed he had a staff member with him until he was discharged on 04/20/26. Record review of the facility's policy titled Wandering and Elopements dated 11/15/26, reflected the following The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. 1. Record review of Resident #107's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with discitis (inflammation of the space between spinal bones). Record review of Resident #107's Quarterly MDS Assessment, dated 04/08/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated that the resident was on antibiotics. Record review of Resident #107's Comprehensive Care Plan, dated 04/14/2026, reflected that the resident was on IV therapy related to discitis and one of the interventions was to administer antibiotic medications as ordered. Record review of Resident #107's Physician Order, dated 04/07/2026, reflected Meropenem Intravenous Solution Reconstituted 500 MG (Meropenem) Use 500 mg intravenously every 8 hours related to DISCITIS, UNSPECIFIED, MULTIPLE SITES IN SPINE . until 05/01/2026 23:59. During an observation on 04/21/2026 at 7:56 a.m. revealed that RN E was about to disconnect Resident #107's IV. It was observed that an opened container of germicidal wipes (substance that destroys germs and microorganisms) was on top of the resident's side table beside some snacks and a box of wipes. During an interview on 04/21/2026 at 8:06 a.m., Resident #107 said he did no know who left the container of germicidal wipes on his side table. He said it had been there for quite some time. During an interview on 04/21/2026 at 10:02 a.m., RN E said she already took the container of germicidal wipes from Resident #107's room. She said she did not know who left it inside the resident's room. She said the germicidal wipes had chemicals in them that could cause skin irritation; that was why the staff used gloves when handling them. She said residents might use the wipes to clean their eyes and faces that could result in irritation. 2. Record review of Resident #110's Face Sheet, dated 04/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with acute cystitis (inflammation of the urinary bladder) with hematuria (blood in the urine). Record review of Resident #110's Comprehensive MDS Assessment, dated 04/10/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had acute cystitis with hematuria. Record review of Resident #110's Comprehensive Care Plan, dated 04/22/2026, reflected that the resident is on IV medications (ABT) r/t acute cystitis and one of the interventions was to monitor midline placement. Record review of Resident #110's Physician Order, dated 04/21/2026, reflected Meropenem Intravenous Solution Reconstituted 500 MG (Meropenem) Use 500 mg intravenously at bedtime for ESBL (Extended-Spectrum Beta-Lactamasesin: bacteria that could cause infection) Urine for 5 Days. During an observation 04/21/2026 at 5:40 a.m. revealed a container of germicidal wipes was on the floor in-front of Resident #110's room. During an observation and interview on 04/21/2026 at 5:46 a.m., RN C said he did not know who left the germicidal wipes in front of Resident #110's room. He said residents passing by could get some and use it to clean the eyes, causing irritation. During an interview on 04/21/2026 at 6:01 a.m., CNA G said she was not the one who left the container of germicidal wipes on the floor. She said the wipes might cause harm especially when used to wipe the genitals. During an interview on 04/23/2026 at 6:26 a.m., the DON said the container of germicidal wipes should not be within reach of the residents because the wipes were harmful if consumed. She said the germicidal wipes should be stored inside the last drawer of the cart for safe keeping. She said the germicidal wipes on the floor might have been left by a CNA that would use it to clean Resident #110's equipment. She said germicidal wipes should not be left inside the rooms of the residents near their food and ordinary wipes. She said the resident might accidentally pull the germicidal wipes instead of the ordinary wipes and use them. She said the expectation was for the staff to not leave the germicidal wipes unattended and within reach of the residents. She said she would start an in-service regarding the disinfectants. During an interview on 04/23/2026 at 709 a.m., the ADON said the container of germicidal wipes should not be within reach of the residents, not on the floor or inside the rooms of the residents, for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin, and could result in irritations. She said some residents might consume it. She said anything that had Keep out of reach of children as an instruction should be considered harmful because the facility had confused residents that may not know germicidal wipes from ordinary wipes. She said the DON had already started an in-service about germicidal wipes being left unattended. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the germicidal wipes should have been secured because the facility had confused residents that could use the wipes inappropriately. She said the DON had already started an in-service about the germicidal wipes. Record review of the facility's policy Storage of Medications 2001 MED-PASS, Inc. revised April 2019 reflected Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 7. Antiseptics, disinfectants, and germicides used in any aspect of resident care have legible, distinctive labels that identify the contents and the directions for use and are stored separately from regular medications.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of twenty residents (Residents #63, #71, #79, #102, and #107) and one of four direct care staff (MA K) reviewed for medication storage. 1. The facility failed to ensure that Resident #71 did not have a pain reliever cream inside his room on 04/21/2026. 2. The facility failed to ensure that Resident #102 did not have a tube of zinc oxide and a bottle of multivitamins inside her room on 04/21/2026. 3. The facility failed to ensure that Resident #63 did not have a tube of zinc oxide inside her room on 04/21/2026. 4. The facility failed to ensure that Resident #79 did not have a tube of zinc oxide inside her room on 04/21/2026. 5. The facility failed to ensure that Resident #107 did not have a roll-on pain relief and a tube of zinc oxide on 04/21/2026. 6. The facility failed to ensure that a container of biofreeze was not left unattended on MA K's medication cart on 04/21/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #71's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with spondylosis (arthritis of the spine) and radiculopathy (condition caused compression of the nerves in the spine). Record review of Resident #71's Comprehensive MDS Assessment, dated 02/05/2026, reflected that the resident had an intact cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had spondylosis and radiculopathy. Record review of Resident #71's Comprehensive Care Plan, dated 02/08/2026, reflected that the resident had an ADL self-care performance deficit related to pain and surgery, and one of the interventions was to assist with personal hygiene. During an observation and interview on 04/21/2026 at 6:01 a.m. revealed Resident #71 was in his bed, awake. It was observed that a tube of pain reliever cream was on top of his side table, beside some foods and drinks, and was in plain view. The resident said the pain reliever cream had always been on his side table, and nobody asked him about it. He said it was not his first tube of pain reliever cream. 2. Record review of Resident #102's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest), and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #102's Comprehensive MDS Assessment, dated 03/05/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had depression, and dementia and was incontinent for bladder. Record review of Resident #102's Comprehensive Care Plan, dated 03/07/2026, reflected that the resident had an ADL self-care performance deficit and was using an antidepressant and the interventions were to assist with toilet use and to give anti-depressant as ordered. Record review on 04/22/2026 of Resident #102's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 04/21/2026 at 5:52 a.m. revealed Resident #102 was in her bed, awake. It was observed that a tube of zinc oxide, two sachets of zinc oxide (medicated cream used to prevent skin irritation), and a bottle of multivitamins were on top of the resident's side table. The resident said the staff used the zinc oxide when they cleaned her and changed her brief. She said the vitamins were hers, and the staff knew she had a bottle of multivitamins inside her room. During an interview on 04/21/2026 at 6:09 a.m., RN C said he did not notice that Resident #71 and Resident #102 had medications inside their rooms. He said he would talk to the residents and explain to them that they should not have medications inside their rooms. He said for the multivitamins, the staff did not know how often and how much the resident was taking her multivitamins and that could result in overdose. He said even the pain-relieving cream could result in skin irritation depending on how often it was used. 3. Record review of Resident #63's Face Sheet, dated 04/23/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia and age-related cognitive decline (gradual loss of cognitive abilities). Record review of Resident #63's Comprehensive MDS Assessment, dated 03/21/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was at risk of developing pressure ulcers. Record review of Resident #63's Comprehensive Care Plan, dated 03/25/2026, reflected that the resident had impaired cognitive function or impaired thought process r/t dementia and one of the interventions was to reorient as needed. Record review on 04/23/2026 of Resident #63's Clinical Assessment Notes reflected that the resident did not have an assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 04/21/2026 at 9:06 a.m. revealed Resident #63 was in her bed, awake. It was observed that an open sachet of zinc oxide was on top of the resident's side table. She said the staff gave it to her so she could put it on her bottom when it was sore. 4. Record review of Resident #79's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a disorder that primarily affects memory), transient visual loss (temporary or sudden loss of vision), and incontinence for bowel and bladder. Record review of Resident #79's Comprehensive MDS Assessment, dated 01/29/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #79's Comprehensive Care Plan, dated 02/01/2026, reflected that the resident had bladder and bowel incontinence and one of the interventions was to apply barrier cream after each incontinent care. Record review on 04/22/2026 of Resident #79's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 04/21/2026 at 9:43 a.m. revealed that Resident #79 was in her wheelchair, awake. It was observed that a tube of zinc oxide was on top of the resident's side table and was in plain view. She said the staff would use it when they changed her. She said the staff always leave the tube for zinc oxide on top of her side table and very seldom put it in her drawer. 5. Record review of Resident #107's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with complex regional pain syndrome (chronic pain condition that typically affects an arm or a leg) and benign hypostatic hyperplasia (enlarged prostate). Record review of Resident #107's Comprehensive MDS Assessment, dated 04/08/2026, reflected that the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had complex regional pain syndrome and benign hypostatic hyperplasia. Record review of Resident #107's Comprehensive Care Plan, dated 04/14/2026, reflected that the resident had discitis and one of the goals was for the resident to be free from discomfort. Record review on 04/22/2026 of Resident #107's Physician Order reflected that the resident did not have orders for roll-on pain relief. During an observation and interview on 04/21/2026 at 8:06 a.m., revealed Resident #107 was in hid bed, awake. it was observed that a tube of zinc oxide and a roll-on pain reliever was on top of the resident's overbed table. The resident said they used the zinc oxide when they were changing him. He said the roll-on pain relief was his medication, and if it was not on his overbed table, it would be on his side table. During an interview on 04/21/2026 at 10:02 a.m., RN E said he had already talked to Resident #107 about the medication inside his room. She said there should be no medications inside the rooms of the residents because the staff could not monitor how often the resident was using the medication. She said the tube of zinc oxide should not be left within reach of any resident because it could be harmful when consumed. She said she asked around, but nobody knew who left the tube and sachets of zinc oxide inside the resident's room. 6. During an observation on 04/21/2026 at 6:32 a.m. revealed a container of biofreeze was inside the bin at the side of MA K's medication cart. It was observed that MA K left her cart in the hallway unattended when she went to the dining area to talk to a resident.During an observation and interview on 04/21/2026 at 6:36 a.m., MA K said she did not know who placed the container of biofreeze at the side of her cart. She said biofreeze was a medication and should not be left unattended because residents might take them and hide it inside the room and use it inappropriately when nobody was looking. She said the residents might consume them or use them in their eyes. She took the container of biofreeze and gave it to LVN F. During an observation and interview on 04/21/2026 at 6:40 a.m., LVN F took the biofreeze that MA K gave him and put it inside his cart. He said he did not know who placed it at the side of MA K's cart. He said medications should be locked inside the cart and not left unattended because it could be harmful to the residents if they get hold of it and consume it. During an interview on 04/23/2026 at 6:26 a.m., the DON said medications, whether oral or topical, should not be inside the residents' rooms because the residents might use them inappropriately and that could result in adverse reactions, such as overdosing. She said skin barriers were applied topically and could be harmful when ingested. She said the expectation was for the staff to be vigilant when they entered the residents' room to check for any medications and for staff using the skin barriers to not leave the tubes within reach of the residents. She said pertaining to the biofreeze outside the cart, MA K became responsible when she started using the cart, so she should have checked the outside of the cart as well. She said she would talk to the residents and see if they really needed the medications so she could request orders for the medications mentioned. She said she had already started an in-service about medication storage. During an interview on 04/23/2026 at 709 a.m., the ADON said barrier creams with zinc oxide should not be within reach of the residents. She said confused residents might mistakenly consume them or use them inappropriately. She said the barrier creams should be somewhere not accessible to the residents. She said medications, such as multivitamins and topical analgesic, should not be inside the residents' rooms for the same reason. She said if the residents needed the multivitamins and the pain reliever, then the staff should be the one giving it to them or applying it to them. She said the DON had already started an in-service about medication storage. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the expectation was for the staff to make sure there were no medications and barrier creams inside the residents' rooms because the residents might consume them or use them on their eyes causing irritation. She said she was not a clinician and would let the DON take the lead on the issue of medications inside the rooms of the residents. Record review of the facility's policy Administering Medications 2001 MED-PASS, Inc. revised April 2019 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . 3. Medications are administered in accordance with prescriber orders. Record review of the facility's policy Storage of Medications 2001 MED-PASS, Inc. revised April 2019 reflected Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 1. Drugs and biologicals used in the facility are stored in locked compartments . 3. The nursing staff is responsible for maintaining medication storage. Record review of the facility's policy Medication Orders reflected Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . Supervision by a Physician . 2. A current list of orders must be maintained in the clinical record of each resident.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of twenty residents (Resident #4, #32 and #71) reviewed for infection control. 1. The facility failed to ensure CNA J did not put Resident #4's catheter bag on top of the resident's bed and changed her gloves after touching the catheter bag on 04/22/2026. 2. The facility failed to ensure CNA H performed hand hygiene and changed her gloves during Resident #32's incontinent care on 04/22/2026. 3. The facility failed to ensure CNA G wore a gown when she emptied Resident #71's catheter bag and when she checked if the resident was wet on 04/21/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #4's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with reflux neuropathic bladder. Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter. Record review of Resident #4's Care Plan, dated 04/15/2026, reflected that the resident had a Foley catheter r/t reflux neuropathic bladder and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of Resident #4's Physician Record, dated 03/12/2026, reflected Catheter: Urinary Catheter change Foley catheter bag and accessories size: _16 fr___, bulb: 10cc_every day shift every 30 day(s). During an observation on 04/22/2026 at 2:15 p.m. revealed CNA I and CNA J were about to do Resident #4's incontinent care. They both washed their hands before putting on gowns and pairs of gloves. During the process of incontinent care, CNA J told CNA I to hand her the resident's catheter bag. CNA I handed over the resident's catheter bag to CNA J and CNA J placed the catheter bag on top of the bed, near the resident's feet. The right foot was noted to have a wound with dressing. The catheter bag was on top of the bed all throughout incontinent care and was entangled on the resident's blanket. When CNA I was cleaning the resident, CNA J assisted with fixing the brief without changing her gloves. After incontinent care, CNA I used the same blanket that had contact with the catheter bag to cover the resident. During an interview on 04/22/2026 at 2:36 p.m., CNA I said it did not occur to him that the catheter bag was dirty and should not be on top of the bed touching the linens that Resident #4 was using. He said placing the catheter bag on top of the bed could result in cross contamination. During an interview on 04/22/2026 at 2:40 p.m., CNA J said it did not occur to her that the catheter bag should not be placed on top of the bed because it was dirty. She said placing the catheter bag on top of the bed could cause infection. She said since the catheter bag was dirty, then she should have changed her gloves after touching it, 2. Record review of Resident #32's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with urinary tract infection and prostatic hyperplasia. Record review of Resident #32's Comprehensive MDS Assessment, dated 03/20/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had bowel and bladder incontinence. Record review of Resident #32's Comprehensive Care Plan, dated 04/03/2026, reflected the resident had bladder incontinence and one of the interventions was to clean the perineal area after each episode. During an observation on 04/22/2026 at 9:40 a.m. revealed CNA H was about to do Resident #32's incontinent care. She washed her hands and put on a pair of gloves. She then went on the other side of the bed to get the trash can. After touching the trash can, she took the brief from the resident's overbed table, opened it, and placed it at the side of the resident. She cleaned the resident's perineal area using the front to back technique. After cleaning the perineal area, she rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the brief from the side of the resident and placed it under the resident. She did not change her gloves after cleaning the bottom and before touching the new brief. During an interview on 04/22/2026 at 9:51 a.m., CNA H said she should have changed her gloves when she touched the trash can and after she cleaned the resident's bottom because technically her gloves were dirty. She said not changing the gloves after touching something dirty could result in infection. 3. Record review of Resident #71's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with obstructive (a blockage in the urinary tract) and reflux uropathy (urine flows back from the bladder to the kidneys). Record review of Resident #71's Comprehensive MDS Assessment, dated 02/05/2026, reflected that the resident had an intact cognition with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter. Record review of Resident #71's Comprehensive Care Plan, dated 02/08/2026, reflected that the resident had a urinary catheter in place related to obstructive uropathy and one of the interventions was to do Foley care q shift. During an observation on 04/21/2026 at 6:01 a.m. revealed CNA G was about to do Resident #71's incontinent care. It was observed that the resident had a catheter. She went inside the resident's room and emptied the resident's catheter bag. She did not wear a gown while emptying the catheter bag. After emptying the catheter bag, she checked the resident's brief to see if it was wet. In the process of checking the resident, it was observed that she was leaning on the catheter's tubing and catheter bag. It was observed that there was sign outside the resident's room that the resident was on EBP During an interview on 04/21/2026 at 6:17 a.m., CNA G said Resident #71 had a catheter and she should have worn a gown. She looked at the sign outside, and saw that a gown was required during catheter care. She said the risk could be transferring microorganisms from one resident to another. During an interview on 04/23/2026 at 6:26 a.m., the DON said if a resident was on EBP, then the staff doing care should wear a gown every time they had contact with the resident to prevent cross contamination and spread of infection. She said for a resident with a catheter, a gown was needed to empty the catheter bag and to do incontinent care. She said gloves should have been changed after cleaning the resident's bottom and after touching the trash can and the catheter bag to make sure they were using clean gloves when touching the new brief. She said the catheter bag should not have been placed on top of the bed because it was dirty. She said, since the catheter bag already touched the linens, then it should not be used to cover the resident again. She said the concerns discussed were all infection control issues. She said the expectation was for the staff to wear a gown when needed, change their gloves after touching anything dirty, and not to place anything dirty on top of the bed. She said she already started an in-service about hand hygiene and EBP and would add not placing the catheter bag on top of the bed. During an interview on 04/23/2026 at 709 a.m., the ADON said the staff should have sanitized their hands and changed their gloves after touching the trash can, the catheter bag, and after cleaning the resident's bottom because the gloves were technically dirty. She said the facility's protocol was to go from clean to dirty and not the other way around. She said she was not sure if the catheter bag was dirty because it was a closed circuit, but the best practice was not to put it on top of the bed. She said, as per the mandate of CDC, gowns should be worn when a resident was on EBP to prevent development of infection. She said the DON had already started an in-service about infection control. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the expectation was for the staff to be mindful not to spread any infection and that the staff would adhere to the policy of hand hygiene, EBP, and infection control. She said she was not a clinician and would let the DON take the lead on the issue of infection control. Record review of the facility's policy Infection Control Guidelines for All Nursing Procedures . Purpose: To provide guidelines for general infection control while caring for residents . General Guidelines . 3. Employees must wash their hands . c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin . In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub . e. Before handling clean or soiled dressings, gauze pads, etc. f. Before moving from a contaminated body site to a clean body site during resident care . h. After handling used dressings, contaminated equipment, etc. 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Record review of the facility's policy Implementation of Standard and Transmission-Based Precautions revised March 2024 reflected Policy Statement: Infection control measures are implemented in attempts to prevent the spread of communicable diseases . 3. Enhanced Barrier Precautions (EBP) - Expand the use of PPE and refer to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . Examples of Enhanced-Based Precaution residents . Indwelling medical devices . urinary catheter . II. Enhanced-Based Precautions are indicated during . Providing hygiene . Changing briefs . Device care or use . urinary catheter.

Based on observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #26) reviewed for respiratory care. The facility failed to ensure Resident #26's BiPAP mask was properly stored when not in use on 04/21/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #26's Face Sheet, dated 04/21/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a solitary pulmonary nodule. Record review of Resident #26's Comprehensive MDS Assessment, dated 03/31/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a solitary pulmonary nodule. The resident's next ARD was 07/01/2026. Record review of Resident #26's Comprehensive Care Plan, dated 04/17/2026, reflected that the resident did not have a care plan for her BiPAP. Record review of Resident #26's Physician Order, dated 04/16/2026, reflected BIPAP IPAP 10, EPAP-6 QHS & PRN/NAPS at bedtime related to SOLITARY PULMONARY NODULE. Record review of Resident #26's Physician Order, dated 04/16/2026, reflected Ensure CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open)/BIPAP humidification chamber is full and clean. Clean CPAP/BIPAP mask, nasal pillows, and with soap and water and allow them to air dry between uses. When dry and not in use, store them in a covered device (e.g., plastic bag, etc.). Clean Headgear (strap) with warm, soapy water and mild detergent as needed. Allow to air dry. During an observation and interview on 04/21/2026 at 9:10 a.m., revealed Resident #26 in her bed, awake. It was observed that a BiPAP mask was on the resident's side table, unbagged. The resident said the mask had been on her side table since the night before. She said that since last night, approximately six staff already went back and forth to check on her but did not say anything about her mask being on top of the table. She said the staff did not give her bag where she could put the mask. During an interview on 04/21/2026 at 9:47 a.m., RN D said she did not notice that Resident #26's BiPAP mask was not bagged when she checked on her. She said she would get a bag, clean the BiPAP mask, and put it inside the bag. She said the mask should be bagged to prevent respiratory infection. During an interview on 04/23/2026 at 6:26 a.m., the DON said the BiPAP mask should be inside a plastic bag when not in use to maintain its cleanliness as well as its patency (unobstructed). She said bagging the BiPAP mask was important to prevent cross contamination and development of infections. She said the staff were responsible for bagging the mask or at least provided a bag and educated the resident of the reason why the mask should be bagged. She said she already started an in-service about bagging the BiPAP mask. During an interview on 04/23/2026 at 709 a.m., the ADON said the BiPAP masks should be in a plastic bag when not in use to prevent cross contamination and respiratory infection. She said the staff were responsible for bagging the mask. She said the DON had already started an in-service about respiratory care. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said everything that the residents were using for their respiratory issues should be kept clean to prevent any respiratory issues. She said the DON had already started an in-service about respiratory care as soon as she heard the BiPAP mask was not bagged. She said she would coordinate with the DON and the ADONs to provide additional in-services and monitor their compliance. Record review of the facility's policy CPAP/BiPAP Support 2001 MED-PASS. Inc. revised April 4, 2025, reflected Purpose . 3. To promote resident comfort and safety . General Guidelines for Cleaning . 5. Masks, nasal pillows, and tubing: . Place and store mask in covered device (i.e. plastic bag, kangaroo pouch, etc.,) between uses.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for one of twenty residents (Resident #4) reviewed for privacy and confidentiality. The facility failed to ensure CNA I and CNA J closed the blinds of Resident #4's window, which was overlooking the parking lot, during incontinent care on 04/22/2026. This failure could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care.Findings included: Record review of Resident #4's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with lumbar spina bifida (the spinal cord fails to form during pregnancy) and weakness. Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident had bowel incontinence (unable to control). Record review of Resident #4's Care Plan, dated 04/15/2026, reflected that the resident had an ADL self-care performance deficit related to spina bifida and one of the interventions was to assist during toilet use. During an observation on 04/22/2026 at 2:15 p.m. revealed CNA I and CNA J were about to do Resident #4's incontinent care. It was observed that the resident's bed was parallel to the window, was overlooking the parking lot, and did not have a curtain. CNA J closed the door, while CNA I prepared to do incontinent care, but did not close the window blinds. In the process of incontinent care, CNA I exposed the resident's genital area until the conclusion of the incontinent care. At this point, the blinds were still open. During an interview on 04/22/2026 at 2:36 p.m., Resident #4 said the staff never closed his blinds when they were changing him and he got used to it. During an interview on 04/22/2026 at 2:39 p.m., CNA I said he was focused on doing the right procedure for incontinent care that he forgot to close Resident #4's blinds. He said the blinds should be closed, as well, when doing incontinent care. During an interview on 04/22/2026 at 2:41 p.m., CNA J said the blinds should have been closed to provide privacy. She said if the doors were closed and the privacy curtains were pulled, then the blinds should also be closed. During an interview on 04/23/2026 at 6:26 a.m., the DON said the staff should have closed the blinds during incontinent care so that the resident would not be exposed from the parking lot. She said, the issue was not if the residents minded or not, but that the staff did not provide privacy. She said all the staff were expected to provide full privacy during care. The DON stated she would start an in-service about privacy and would personally monitor if the staff were in compliance with the policy. During an interview on 04/23/2026 at 709 a.m., the ADON said the best practice was to close the blinds while doing incontinent care to provide privacy. She said staff closed the doors and pulled privacy curtains to provide privacy from the inside of the facility so why not close the blinds as well to provide privacy from the outside of the facility. She said the DON had already started an in-service about privacy. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the best practice was to provide privacy during incontinent care. She said the expectation was for the staff to provide privacy during care, not just during incontinent care. She said she would collaborate with the DON about the issue regarding privacy. Record review of the facility's policy, Resident Rights 2001 MED-PASS, Inc. revised October 4, 2022, reflected Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation . 1. Federal and state laws guarantee certain basic rights to all residents of this facility . t. privacy. Record review of the facility's in-service Resident Rights to Privacy, dated 04/23/2026, reflected During resident car, privacy needed to be maintained at all times, doors and blinds need to be closed.

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) to meet the needs of each resident for one of ten residents (Resident #83) reviewed for pharmaceutical services. The facility failed to ensure LVN F did not administer Resident #83's esomeprazole along with the other medications and the resident's formula on 04/22/2026. This failure placed residents at risk of not receiving the full benefit of their medication. Findings included: Record review of Resident #83's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing) and gastro-esophageal reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #83's Comprehensive MDS Assessment, dated 04/07/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident had a feeding tube and had gastro-esophageal reflux. Record review of Resident #83's Comprehensive Care Plan, dated 04/06/2026, reflected the resident was not care planned for his feeding tube and GERD. Record review of Resident #83's Physician Order, dated 04/03/2026, reflected ESOMEPRAZOLE 40 MG PACKET Give 1 packet via PEG-Tube (procedure to place a feeding tube in the stomach) one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (inflammation of the esophagus) . MIX W/15 CC OF H2O & LET SET FOR 2-3 MINS & GIVE PER G-TUBE EVERY DAY THEN FLUSH WITH 15 ML OF WATER. The order did not specify to give to give the medication on an empty stomach. Record review of Resident #83's Physician Order, dated 04/03/2026, reflected Coreg Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF SBP < 110 AND DBP < 60 AND HR < 60. Record review of Resident #83's Physician Order, dated 04/03/2026, reflected Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet via G-Tube one time a day related to VITAMIN DEFICIENCY, UNSPECIFIED. Record review of Resident #83's Physician Order, dated 04/03/2026, reflected Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet via G-Tube two times a day related to CONSTIPATION, UNSPECIFIED. Record review of Resident #83's Physician Order, dated 04/13/2026, reflected five times a day Enteral (delivery of food through feeding tube): Enteral Nutrition via Bolus (large dose of medication or food given at once): Diabetisource AC give 1 can (250 ml) Five times per day) via bolus per Gtube) at 0800, 1200, 1600, 2000 and 0000. 1500 ___ kcal, 75 __ grams protein, _1920 ml___ free water. During an observation on 04/22/2026 at 8:11 a.m. revealed LVN F was about to administer Resident #83's medication via g-tube. He prepared five medications and one of them was esomeprazole. After preparing the medications, he went inside the resident's room and started to administer the medications. He flushed the g-tube with 30 cc of water and administered the medications one-by-one and flushing in between with 30 cc. The last medication administered was the esomeprazole. After administering the omeprazole, he flushed the g-tube with 30 cc of water then flushed it again with 90 cc of water, gave the formula, and flushed it again with 90 cc of water. The omeprazole was not given on an empty stomach.During an interview on 04/22/2026 at 8:49 a.m., Resident #83 said his medications in the morning were given to him at the same time. He said there was no medication that was given to him before the other medications. During an interview on 04/22/2026 at 9:09 a.m., the DON said she would ask the pharmacist about the esomeprazole regarding when and how it should be administered. During an interview on 04/22/2026 at 10:07 a.m., the DON said she already talked to the pharmacist and was informed that the esomeprazole should be given by itself and not administered with the other medications and in an empty stomach to ensure effectiveness of the medication. She said she already talked to LVN F about the esomeprazole being given by itself. She said LVN F already changed the order for Resident #83's esomeprazole. She said they would also audit if other residents were taking esomeprazole and would change the order as appropriate. During an interview on 04/22/2026 at 12:09 p.m., LVN F said he had already changed the schedule of Resident #83's esomeprazole to one hour before the rest of his medications and morning formula. He said the rationale behind giving the esomeprazole by itself was to make sure the medication was absorbed effectively. He said the gastric juice, that would be triggered by food or liquid, could hamper absorption of the medication. During an interview on 04/23/2026 at 709 a.m., the ADON said esomeprazole should be given 30 minutes to one hour before food and medications to ensure absorption of the medication. She said the DON already talked to LVN F and changed the time for the esomeprazole. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said she was not a clinician and would let the DON handle the issue about the esomeprazole Record review of the facility's policy Administering Medications 2001 MED-PASS, Inc. revised April 2019 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 4. Medication administration times are determined by resident need and benefit. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one of twelve residents (Resident #26) reviewed for care plans. The facility failed to ensure that Resident #26 had a care plan for her BiPAP on 04/21/2026.This failure could place the residents at risk of not receiving the necessary care and services.Findings included: Record review of Resident #26's Face Sheet, dated 04/21/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a solitary pulmonary nodule (a single round spot in the lung). Record review of Resident #26's Comprehensive MDS Assessment, dated 03/31/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a solitary pulmonary nodule. The resident's next ARD (assessment reference date: specific date that marks the end of observation) was 07/01/2026. Record review of Resident #26's Comprehensive Care Plan, dated 04/17/2026, reflected the resident did not have a care plan for her BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). Record review of Resident #26's Physician Order, dated 04/16/2026, reflected BIPAP IPAP (inspiratory positive airway pressure: pressure delivered during inhalation) 10, EPAP (expiratory positive Airway pressure: lower pressure applied during exhalation) -6 QHS & PRN/NAPS at bedtime related to SOLITARY PULMONARY NODULE. During an observation and interview on 04/21/2026 at 9:10 a.m., revealed Resident #26 in her bed, awake. It was observed that a nasal pillow BiPAP mask was on top of her side table. The resident said the Respiratory Therapist brought the BiPAP five days ago and had been using it since then. During an observation and interview on 04/23/2026 at 6:08 a.m., the MDS Coordinator said Resident #26's BiPAP should have been care planned when she started using it. She said it was not communicated to her that the resident started using the BiPAP, so the staff would know if it was effective and if the resident was doing it right. She said anybody could do the care plan for the BiPAP. She said whoever transcribed the order could have done the care plan. She said it was the ADON who transcribed the order for the BiPAP. During an interview on 04/23/2026 at 6:26 a.m., the DON said Resident #26's BiPAP should have been care planned and should have been communicated to the MDS Coordinator so the MDS Coordinator could have made a care plan for it. She said ADON A do not do care plans but should have communicated it to the MDS Coordinator.During an interview on 04/23/2026 at 7:09 a.m., the ADON said the MDS Coordinator was the one doing the care plans. She said whatever was new, like a change in condition about a particular resident was discussed during the morning meeting, and she did not know why the BiPAP was not captured. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said that all the residents should have a care plan in line with their needs. She said without the care plan, the staff would not know the goals and the interventions needed by the residents. She said the expectation was for all the residents to be care planned appropriately. She said she would coordinate with the DON and the MDS Coordinator to make sure all the residents were care planned. Record review of the facility's policy Care Plans, Comprehensive Person-Centered Care Plan reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #4) reviewed for incontinent care. The facility failed to ensure that CNA J did not place Resident #4's catheter on top of the Resident #4's bed rendering the catheter not below the bladder for the duration of incontinent care on 04/22/2026. This failure could place the residents at risk of backflow of urine resulting to urinary tract infection.Findings included: Record review of Resident #4's Face Sheet, dated 04/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with reflux neuropathic bladder (bladder does not function properly due to damaged nerves). Record review of Resident #4's Comprehensive MDS Assessment, dated 03/14/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #4's Care Plan, dated 04/15/2026, reflected that the resident had a Foley catheter r/t reflux neuropathic bladder and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of Resident #4's Physician Order, dated 03/12/2026, Catheter: Urinary Catheter change Foley catheter bag and accessories size: _16 fr (French: unit of measurement for catheter sizes) ___, bulb: 10cc___every day shift every 30 day(s). During an observation on 04/22/2026 at 2:15 p.m. revealed CNA I and CNA J were about to do Resident #4's incontinent care. During the process of incontinent care, CNA J told CNA I to hand her the resident's catheter bag. CNA I handed over the resident's catheter to CNA J and CNA J placed the catheter bag on top of the bed, near the resident's feet. It was observed that the tube of the catheter had urine in it. The catheter bag was on top of the bed all throughout incontinent care. During an interview on 04/22/2026 at 2:36 p.m., CNA I said when he handed over Resident #4's catheter bag, it did not occur to him that she would put it on top of the bed. He said, what he knew was that the catheter bag should always be below the bladder to prevent urine in the catheter bag going back inside the resident. During an interview on 04/22/2026 at 2:40 p.m., CNA J said it did not occur to her that the catheter bag should not be placed on top of the bed and should be always below the bladder because it could result to urinary tract infection. She said she asked for the catheter bag and placed it on the top of the bed because she was afraid that they might pull the catheter tube when they turn the resident. She said she should have hung the catheter bag on the other side of the bed when they turned the resident. During an interview on 04/23/2026 at 6:26 a.m., the DON said the catheter bag should always be below the bladder to prevent backflow of urine from the catheter bag to the bladder. She said if there was a backflow, it could result to urinary tract infection. She said the staff could always hang the catheter bag to the other side of the bed if they need to turn the resident. She said the expectation was for the staff to always hang the catheter bag below the bladder. She said she would start an in-service about catheter care. During an interview on 04/23/2026 at 709 a.m., the ADON said the catheter bag should have been hung on the other side of the bed to keep the bag below the bladder to prevent the possibility of urinary tract infection. She said the DON had already started an in-service about catheter care. During an interview on 04/23/2026 at 7:41 a.m., the Administrator said the expectation was if the catheter bag should be below the bladder, then it should always be below the bladder. She said the DON had already started an in-service about catheter care. Record review of the facility's policy Catheter Care, Urinary 2001 MED-PASS, Inc. revised January 3, 2023, reflected Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review, the facility failed to ensure the nurse staffing data information was posted daily for 1 of 1 facility reviewed for required postings.The facility failed to post the daily staffing information for 04/20/26.This failure could place residents, family members, and visitors at risk of not having access to information regarding staffing data and facility census.Findings included:During an observation on 04/21/26 at 5:35 AM, revealed a document labeled Daily Staffing Log and dated 04/19/2026 which was posted in a plastic protector on a desk in the entranceway across from the ADMIN's office. The document included the staff titles: Registered Nurse, Licensed Vocational Nurse, Certified Nurse Aide, Certified Med Aide. The document included the number of staff under each title, the number of hours, the total number of hours worked for each staff title type, the total number of hours worked, and the daily census. Record review on 04/21/26 at 11:45 AM, of the facility's nursing staff information reflected the facility failed to complete and post the nursing staff information on the following dates: 04/20/26. During an interview on 04/23/26 at 10:54 AM DON stated she was aware of the required posted document for Nurse Staffing, but indicated she is not the one responsible for posting the daily nurse staffing and census document. The is done by the HR representative, and added they have an administrative staff member post this daily for the facility. She said the posting showed the staff coverage for the facility based on the census for the residents and if it were not posted then family or visitors would not have the information.During an interview on 04/23/26 at 1:55 PM HR stated that the task of posting the Daily Nurse Staffing Information had been assigned given to the administrative staff. On the date in question when you all showed up in the morning, she hadn't had the opportunity to replace it with the current one. HR could not provide a reason as to why the updated Daily Nurse Staffing Information posting was not done for 04/20/26. HR stated essentially when the administrative staff clocks in the morning. They go by the nursing station takes a picture of the Daily Nurse Staffing Information at the station and then comes to her desk and fills it out. She acknowledged that it was an oversight of not getting it done. During an interview on 04/23/26 at 2:05 PM the ADMIN stated the posting should include the facility name, date, census, with the nursing breakdown which included RNs, MAs, LVNs and & CNAs. The ADMIN stated the posting should include the facility name and the census on the day it was posted but she did not know why the information displayed in the lobby did not have that information. The ADMIN stated the posting is to provide residents, family, and visitors to see what staff were in the facility for the day. She said if the posting were not put up then visitors and residents would not be able to see how the facility was staffed.Record review of an undated facility policy on Posting Direct Care Daily Staffing Numbers, revealed: Policy StatementPolicy Interpretation and ImplementationOur facility will post on a daily basis for each shift the number of nursing personnel responsible for providing direct care to residents.Within 2 hours of the beginning of each shift , the number of Licensed Nurses (RN's, LPNs and LVNs) and the number of unlicensed personnel (CNA's) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. a. The name of the facility b. the date for which the information is posted.c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facilitye. The shift for which the information is postedf. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (east side medication room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the east side medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an observation and interview on [DATE] at 9:16 a.m., expired supplies were found stored on shelves in the east side medication room. Expired supplies observed included: two boxes of 100 count syringes with needles expired on [DATE], two boxes of 100 count syringes with needles expired on [DATE], one box of 100 count syringes with needles expired on [DATE], and four boxes of 100 count syringes without needles expired on [DATE]. LVN A was present during the observation and stated that she thought central supply checked the dates on supplies. However, LVN A stated she was not sure because she was still in training. When asked what the risks were if expired supplies were used, LVN A just stated expired supplies should never be used, and she had not used any of these items found. In an interview on [DATE] at 9:36 a.m., the DON stated the ADONs monitored the medication rooms for expired supplies. The DON reported the ADONs checked the dates on supplies on Mondays and Thursdays. The DON also reported a pharmacy consultant checked the medication room monthly, and Central Supply checked on Wednesdays. When asked what the risks were if expired supplies were used, the DON stated it was best practice not to use expired supplies. In an interview on [DATE] at 10:21 a.m., ADON B stated supplies should be checked for an expiration date by everyone before using it. ADON B stated if supplies were expired, it could affect the integrity and should not be used. ADON B stated central supply should have rotated supply stock and checked the dates. ADON B did not state and was not asked if she checked the dates on supplies. In an interview on [DATE] at 12:30 p.m., Central Supply stated the ADONs were responsible for checking supplies for expiration dates, but one of them was currently sick with COVID. Central Supply stated the pharmacy consultant checked some things, and that he checked the dates on over-the-counter medications stored in the medication rooms. Central Supply stated he did not check the dates on the supplies. Record review of the facility's policy titled Storage of Medications, with a revision date of [DATE], revealed The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner and discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and secured properly for two (500 hall medication cart and 200 hall medication cart) of four medication carts reviewed for medication labeling and storage. 1. The facility failed to ensure eye drops stored on the 500-hall medication cart were labeled with open dates for two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops. 2. The facility failed to ensure medications were secured or attended by authorized staff when the medication cart in hall 200 was left unlocked and unattended in the hallway with a pill in a medicine cup on top of the cart. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations and of not receiving the intended therapeutic effects of prescribed medicine. Findings included: 1. In an interview and observation on 2/11/2025 at 9:46 a.m., the 500-hall medication cart contained two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops that were open and did not have open dates. MA C reported eye drops needed an open date because they were good for 30 or 45 days after being opened. MA C stated the MAs monitored the dates on the medications and wrote open dates on the bottles when they opened them. When asked what the risks were if open dates were not on eye drops, MA C responded they just had to have an open date. In an interview on 2/11/2025 at 10:21 a.m., ADON B stated staff administering medications were supposed to put open dates on eye drops because they were only good for so many days. ADON B stated the risk would be that they would not know how long the medication had been open, and it would depend on the manufacturer as to what side effects occurred. ADON B stated the staff administering the medications should have monitored the dates, and she spot checked the carts two to three times a month. In an interview on 2/12/2025 at 3:20 p.m., the DON stated eye drops needed an open date, so they would know when they were opened. The DON stated she expected the staff to use the manufacturer's expiration date but was not sure at that time. The DON stated the pharmacy consultant was responsible for monitoring the dates on medications in the medication carts, and all staff that administered medications should have checked the dates. The DON stated she expected staff to dispose of expired medications, and that the risk of using expired medications would just depend on the medication. The DON did not state the risk for using expired eye drops or for eye drops not having an open date. In an interview on 2/12/2025 at 3:40 p.m., the DON stated she spoke with her pharmacy consultant, and they did not have to date eye drops. The DON reported they would use the manufacturer's expiration date. In an interview on 2/12/2025 at 3:48 p.m., the pharmacy consultant reported that there were no specific guidelines for artificial eye drops, and they did not require an open date. The pharmacy consultant reported that the length of time other eye drops were good depended on the manufacturer's expiration date or their guidelines. In an interview on 2/12/2025 at 4:04 p.m., the DON stated they would use the manufacturer's expiration date for all eye drops except for Xalatan (latanoprost) because they were only good for a certain number of days after opening. The DON did not state how many days. In an interview on 2/12/2025 at 4:15 p.m., MA E stated prescription eye drops are good for six weeks, and pharmacy consultant told him to throw them away after six weeks. MA E stated he did not know what the risk would be if the eye drops did not have an open date or were used longer that six weeks. MA E stated they put the open dates on the eye drops so that did not happen. MA E also stated that everyone that passed medications was responsible for monitoring the dates on medications in the carts. In an interview and observation on 2/12/2025 at 4:28 p.m., LVN F stated eye drops had open dates, but (HE/SHE) was not sure how long they were good for. Observed LVN F ask LVN G, and LVN G stated eye drops were good for 30 days after opening. In an interview and record review on 2/12/2025 at 4:30 p.m., MA H reported some eye drops were good for 30 days and some were good for 45 days. MA H stated he did not always remember, so he used the information sheet located in the narcotic binder on the medication cart. MA H opened a binder on his medication cart and revealed a sheet titled Medications with Shortened Expiration Dates. This sheet listed several different eye drops and the amount of days the medication could be used after opening. Eye drops that were listed on this sheet included latanoprost and he stated those eye drops were good for 42 days after being opened or removed from the refrigerator. The informational sheet did not specify how many days timolol, dorzolamide, or Brimonidine were good after opening if not mixed with another medication. In an interview on 2/12/2025 at 5:41 p.m., the DON stated they use the information sheet located on the medication cart for prescription eye drops. The DON stated they did not need an open date for over-the-counter eye drops. 2. In an observation on 2/11/2025 at 1:35 p.m., RN D entered a resident's room to administer medications. The medication cart was left approximately three feet in front of the resident's door, unlocked, and had a medicine cup sitting on top of the cart with a pill in it. RN D entered the resident's bathroom inside their room and washed her hands with the door closed. The medication cart was not visible from inside the bathroom. RN D then exited the bathroom and walked next to the resident's bed. The medication cart remained out of view until RN D returned to the cart at 1:39 p.m. (4 minutes later). No residents or visitors were observed in the area of the medication cart while it was unlocked. In an interview on 2/11/2025 at 1:39 p.m., RN D stated she should have locked the cart or pulled it all the way up to the door. RN D stated she also should not have left medication on the top of the cart. RN D stated the risks were that someone could have taken the medication from inside the cart or the pill on top of the cart. In an interview on 2/12/2025 at 5:50 p.m., the DON stated medication carts should always be locked and medications should not be left unattended. The DON stated the carts can be unlocked while passing medications if they were all the way against the resident's door. The DON stated the risks were that medications could go missing, and the staff administering medications should be monitoring that the carts were locked. The DON also stated all staff should help monitor and ensure carts were locked. Record review of the facility's policy titled Administering Medications, with a revision date of April 2019, revealed when opening a multi dose container, a date will be put on the container, and during the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. Record review of the facility's policy titled Storage of Medications, with a revision date of April 2019, revealed Unlocked medication carts are not left unattended.

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 in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 3. The facility failed to have dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 4. The facility failed to have the handwashing sink trash receptacles function properly. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen on 02/11/25 at 10:00 AM revealed the following: -Handwashing sink #1's (next to ice machine) trash receptacle did not function properly. When the foot pedal was pressed the small metal cylindrical trash receptacle leaned forward, coming off of the floor and the lid did not open fully. Observations of Reach-in refrigerator on 02/11/25 at 10:07 AM revealed the following: -Left side: -1-64 oz plastic container of Prune juice dated 12/7/24, previously opened on 01/28/25 there was no discard by date. Observations of Walk-in refrigerator on 02/11/25 at 10:12 AM revealed the following: -Left side, first shelf, 2nd row from the top: -1 small zip top bag with a half of a tomato and approximately a quarter of a red onion (both previously opened), dated 2/7/25 and under the used by label on the bag, dated 2/8/25. There was no label of item descriptions, no clear discard by date and unclear if a date was for each item when placed in the bag. -2 extra-large bags of coleslaw salad mix, dated 01/26/25. Manufacturer's 'best by' date 02/07/25. -1 extra-large bag had a half dollar sized brown spot at the top of the product on the back side of the bag. -1 large zip top bag containing a previously opened 5 lbs. bag of salad blend, opened 02/06/25 and discard by date 02/09/25. -Third row from the top:-1 extra-large gray plastic bin filled with red onions had two labels one dated 10/10/24 and the other dated 12/30/24. There was no item of label description and no discard by date. -Bottom row: -1 extra-large clear plastic bin with approximately 13 heads of cabbage dated 01/02/25. There were 4 heads of cabbage that had dried, withered, darkened areas and or yellowed areas on the outer leaves. There was no label of item description, no discard by date. -Left side, second shelf, 2nd row from the top: -1 extra-large zip top bag with 10 plus beef hot dogs in a box labeled beef hot dogs dated 01/26/25, opened 02/10/25, with no discard by date. Second shelf, 3rd row from the top: approximately 3/4 of a loaf of a deli meat ham, previously cut, dated 02/06/25, opened 02/10/25. There was no discard by date. -1- 5 lbs. bag of ground pork dated 02/10/25, there was no label of item description, no manufacturer's 'best by' date, or discard by date. - 1 large zip top bag of sliced lunch meat (1 bologna and approximately 10 chopped ham), dated 02/04/25 and 02/07/25 remained in refrigerator. There was no label of item description. -Bottom shelf: -1 extra-large box of skinless boneless chicken on a tray, dated 02/06/25. There was no discard by date. Right side, first shelf, 3rd row from the top: 1- extra-large zip top bag of grated cheese dated opened 02/03/25, discard by dated 02/28/25. There was no label of item description. -1 extra-large bag of shredded light-yellow cheese dated opened 02/04/25, discard by date 03/04/25. No label of item description. -2 -48 oz (3 lbs.) white plastic containers of Ricotta cheese dated 01/20/25. Manufacturer's used by date 02/01/25. -3rd row from the top: -1 small square plastic container with lid of salad dressing, previously opened dated 02/10/25. There was no label of item description and no discard by date. -1 large square plastic container with lid of ranch dressing, previously opened, dated 02/11/25. There was no label of item description and no discard by date. -1 medium square metal container of ranch dressing, previously opened, dated 02/10/25. There was no label of item description and no discard by date. -4th row from the top: -1 large cylindrical clean plastic container, without a lid, dated 01/25/25, of approximately 42 boiled eggs. There were 3 sealed clear plastic bags containing 12 eggs each and no discard by date; 1 bag previously opened. The opened bag was open to air, containing 6 eggs. There was no opened date and no discard by date. -Second shelf, 3rd row from the top: -1 large zip top bag of approximately 25 pecan halves, previously opened, dated 1/30/25. There was no label of item description and no discard by date. Observations of Dry Storage Room on 02/11/25 at 10:55 AM revealed the following: -Left side, shelf near door, 2nd row: -1 large clear square plastic bin with lid of dry oat circular cereals, previously opened, dated 02/10/2025. There was not label of item description, no discard by date. -1 large clear square plastic bin with lid of dry corn flake cereal, previously opened, dated 02/10/25. There was not label of item description, no discard by date. -1 large zip top bag with a 4 lbs. bag of cheese cake dry mix, previously opened, dated 10/30/24. There was no discard by date. - 1 large zip top bag with a 24 oz. bag of crispy fried onions, previously opened, dated 12/02/24. There was no discard by date. -1 large zip top bag with a 5 lbs, bag of cornbread mix, previously opened, dated 02/10/25. There was no discard by date. -1 large zip top bag with a 13.75 oz box of mashed potato flakes, previously opened, dated 02/11/25, no discard by date. Observations of the Kitchen on 02/13/25 at 11:56 AM revealed the following: -AIT wearing a hairnet walked in the kitchen and did not wash his hands. He went to the Reach-in refrigerator and opened it. He then walked across the area between the steam table and stove to the other side of the kitchen. He left out of the kitchen through a door (with a handle) into the receiving side of the line. He looked at some of the tickets on a stack of trays near the door then came back into the main kitchen space. He did not wash his hands, sanitize his hands, or don gloves. -At 12:09 PM, the [NAME] walked off the line (serving side of the steam table), wearing gloves. She went to get a bowl of fruit from the walk-in refrigerator. Then she walked off the line again to get a spoon and tongs but did not change into new gloves after either departure and return to serving line. -At 12:19 P, the ADM wearing a hairnet, walked into the kitchen (receiving side) then through the 2nd door into the main kitchen space. He walked through the area between the serving side of the steam table and the stove over to the stack of 8 oz cups with handles. He too the cup back across the kitchen to the coffee machine, got some coffee then left out of the kitchen. He did not wash his hands upon entering the kitchen or don gloves. In an interview on 02/11/25 at 10:27 AM with the DM, she stated the ground meat that was in the refrigerator was ground pork, and they put the date on box it came in, but the box was usually kept in the freezer except for when the ground pork was being used for a dish. The one in the refrigerator had been set out to be used for baked ziti. She stated that is why [NAME] B put it there. In an interview on 2/13/25 at 01:56 PM with the DM, she stated previously opened liquids in the refrigerator were kept until the date (manufacturer's best by date) on the bottle or box. She stated if it is mixed like nectar thick liquids then it kept for 7 days. For premade salad mixes/blends, she stated they kept it until the 'best by' date but opened salad mixed are kept for 7 days from opened date. She stated the beef hot dogs, since opened, are kept 7 days from opened date but 1-2 months if kept in the freezer. The DM sated if the ground pork is kept 7 days in the refrigerator, but if it had been opened then kept for 3 days. She stated the bag with the tomato & onion should not have been labeled like that, with no clear date the harm is it could cause a resident to get sick since you do not know the clear date opened or discard by. For the skinless boneless chicken, the DM stated if she is going to use it within the week then she does not freeze the chicken, so the date that was seen on the box was the date it came in. For dairy and other items with a manufacturer's date she stated they usually go by the expiration date on the container but if it is opened, then 3 days. For items previously opened and left opened to air, the DM stated that can lead to foodborne illness and residents getting sick. She mentioned they have a food guideline sheet they use to know how long to keep items in the kitchen. When she was told about the observations of staff hand hygiene concerns, she stated that is something she talks about a lot and it can result in making the residents sick. In an interview on 02/13/25 at 03:46 PM with the ADM, when he came to the conference room to ask about concerns in the kitchen, he stated his dietician came in every Monday. He stated as a favor to him, she inspects the kitchen. He said, the kitchen, I can't believe it. He stated he was just thinking the citation was just for unlabeled cheese. The surveyor mentioned other items specifically found in the kitchen. The ADM sated he understood it could cause harm to the residents. Review of the facility's Nutrition Services Policy dated 2001: Revision July 2014, reflected Food Storage Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 7. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (''use by date). 13. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: . (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #29) of 19 residents reviewed for medication errors. The facility failed to ensure Clonazepam (a drug used to control seizures and/or anxiety) was administered to Resident #29 as ordered from 9/10/2024 until 2/12/2025 (155 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #29's Annual MDS assessment dated [DATE] revealed Resident #29 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of anxiety disorder and seizure disorder. The MDS also revealed a BIMS score of 13 (it suggested cognition was intact). Record review of Resident #29's care plan revised on 1/24/2025 revealed Resident #29 had a seizure disorder and interventions were to give seizure medications as ordered by the doctor. The care plan also revealed Resident #29 had an anxiety disorder and interventions included administering anti-anxiety medications as ordered by the physician. Record review of Resident #29's physician order summary revealed on 8/12/2024 a new order for clonazepam was entered as clonazepam 0.5 mg with directions to give 0.5 tablet by mouth three times a day and included in directions give 1/2 tablet to equal 0.25 mg. Record review of Resident #29's Narcotic Record logs from 8/11/2024 to 9/09/2024 revealed clonazepam 0.5 mg 1/2 tablet was signed out and marked as given. Record review of Resident #29's Narcotic Record logs from 9/10/2024 until 01/12/25, revealed clonazepam 0.5 mg one tablet was signed out and marked as given. Record review of Resident #29's MARs from 09/10/24, until 01/12/25 revealed clonazepam was administered three times a day by 15 different staff members over a total of 155 days. In an observation on 2/11/2025 at 1:40 p.m., MA C administered one tablet of clonazepam 0.5 mg to Resident #29. Resident #29 was sitting up in his chair and answered MA C's questions appropriately. Resident #29 swallowed the medication and MA C left the room. In an interview and observation on 2/12/2025 at 11:29 a.m., MA C removed Resident #29's clonazepam from the medication cart and stated she administered one whole tablet when she gave the medication. MA C pointed to the directions on the medication card itself which revealed directions to give 0.5 mg one tablet three times a day. MA C opened Resident #29's MAR on her computer screen and read the directions listed for clonazepam which were to give 0.5 tablet. MA C stated that the whole tablet was 0.5 mg and the MAR said to give 0.5 mg. MA C replaced the medication on the locked cart and left to retrieve the ADON to review the medication. In an interview and observation on 2/12/2025 at 11:33 a.m., ADON B reviewed the clonazepam medication located on the cart and stated the directions were to administer one 0.5 mg tablet three times a day. ADON B then reviewed Resident #29's MAR and stated the directions were to administer 1/2 tablet to equal 0.25mg. ADON B then explained to MA C that the 0.5 tablet meant 1/2 tablet and not 0.5 mg. ADON B also demonstrated on the computer screen how to expand the directions for the medication which then revealed to give 1/2 tablet to equal 0.25 mg. ADON B stated staff should have been administering 1/2 tablet, but the medication was delivered wrong by the pharmacy. ADON B stated staff should have checked the dose before administering the medication. ADON B stated the risks to the residents if not receiving the ordered dose depended on the medications, but it could cause sedation. In an interview on 2/12/2025 at 3:20 p.m., the DON stated Resident #29's clonazepam was increased in September due to a transcription error. The DON reported that the nurse that entered the order was not available for interview and was currently off work. The DON stated everyone that administered medications should have followed the five rights of medication administration and monitored the order and dose. The DON stated the pharmacy consultant was also responsible for monitoring medications because she checked the MARs and medications monthly for any concerns. The DON reported staff received training for medication administration upon hire and annually. The DON also stated the risk to the residents if the incorrect dose of medication was given depended on the medication but could be sedation or altered mental status. In an interview on 2/13/2025 at 11:43 a.m., NP D stated she gave an order to increase the clonazepam from 0.25 mg to 0.5 mg, but there must have been a transcription error. NP D stated she did not have any issues or concerns with the facility following orders. NP D also stated there was no risk to the resident because the resident received the intended dose. Review of the facility's policy titled Administering Medications, with a revision date of April 2019, revealed The Director of Nursing Services supervises and directs all personnel who administer medications, and Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record reviews, the facility failed to establish and maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (Resident #85) of three residents reviewed for infection control. The facility failed to ensure RN D used proper infection control precautions when entering the room of Resident #85 who was on droplet precautions due to testing positive for COVID. This failure could place residents at risk for infections. Findings included: Record review of Resident #85's Admission MDS assessment dated [DATE] revealed Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, morbid obesity, and gangrene (dead tissue caused by bacteria or lack of blood flow). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #85's care plan with a revision date of 2/04/2025 revealed Resident #85 was on strict contact isolation related to COVID and interventions included providing proper protective equipment. Record review of Resident #85's order summary revealed strict (contact/droplet) Isolation; Transmission Based Precaution for (Covid +) was ordered on 2/04/2025. In an observation and interview on 2/11/2025 at 1:28 p.m., RN D was preparing to administer medications to Resident #85. A droplet isolation sign was observed on Resident #85's door and isolation supplies were located outside the door in drawers. RN D put on a N95 mask and stated she did not have to wear a gown as long as she did not touch the resident or provide direct care. RN D entered Resident #85's room wearing an N95 mask and no gown, gloves, or face shield. RN D exited the room less than one minute later and placed a medicine cup with a pill in it on top of the medication cart before reentering Resident #85's room. RN D then exited Resident #85's room with a tray and sat the tray on a short table in the center of the hallway. RN D then discarded her mask and cleansed her hands with hand sanitizer. Resident #85 did not cough or appear to have shortness of breath during this time. In an interview on 2/12/2025 at 12:34 p.m., ADON B reported that staff entering a room with a resident on isolation for COVID, should wear a N95 mask, face shield, gown, and gloves. ADON B stated all PPE should be worn even if not providing direct care. ADON B stated the risk was that COVID could be spread. ADON B also stated that trays should not be removed from isolation rooms and placed on a table in the hallway. ADON B reported that the ADONs monitored infection control and the DON performed in-services with staff. ADON B reported there was also training that was done on the computer for isolation precautions and one was assigned to staff recently. Record review of progress note dated 2/12/2025 at 3:02 p.m., entered by ADON B, revealed Resident #85 had been asymptomatic (no symptoms) and could be removed from isolation at that time. In an interview on 2/12/2025 at 4:04 p.m., the DON reported everyone was responsible for monitoring infection control. The DON stated all staff should always wear N95, gown, gloves, and face shield when entering a room with COVID. The DON stated the risk for not wearing appropriate PPE was that the person entering the room could get COVID or spread COVID. Record review of facility's undated policy titled COVID-19 Outbreak-Cheat Sheet, revealed Staff caring for COVID+ patients must wear N95, gown, gloves, and eye protection. All PPE must be discarded and re-applied each time entering COVID room.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. The facility failed to ensure food in the facility's walk-in refrigerator was covered. The facility failed to ensure the ice machine was clean and sanitized. The facility failed to ensure the tea was covered with a lid. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observation on 01/09/2023 from 9:05 AM to 09:20 AM in the facility's kitchen revealed: 1. Two tea dispensers inside the kitchen with tea were not covered. 2. The ice machine inside the kitchen had a brown residue on the side wall. 3. The walk-in refrigerator had mandarin orange slices in a tray without any coverings. An interview with the Dietary Manager on 01/11/2024 at 12:46 PM, she stated the expectation of the kitchen staff was to make the tea an hour before the meal service and the tea dispenser was supposed to be covered during and after the brewing process. She stated the tea was prepared by her staff that day around 7:30 AM which was earlier than expected and both tea dispensers were not covered. She stated she was responsible to ensure the tea dispensers were covered. She stated preparing the tea early would lose its freshness, not covering the tea dispenser may cause cross contamination and could lead to sickness among residents. The Dietary manager stated she expected the ice machine to be clean, free of residue and her staff were to wipe it down daily. She stated an unclean ice machine may cause contamination and make a resident sick . She stated she was responsible to ensure the ice machine was cleaned. The Dietary Manager stated all the food items stored in the refrigerator ready for serving should be covered. She stated the mandarins in the tray were not covered and that may cause contamination and make a resident sick . She stated she was responsible to ensure all food were covered. The Dietary Manager stated she was responsible for the tea dispenser, ice machine and walk-in refrigerator in the kitchen. Interview with the Administrator on 01/11/2023 at 01:18 PM, he stated the expectation was to cover the tea during and after the brewing process. The Administrator stated he did not know the risk for residents because the tea was not covered . The Administrator stated he expected the ice machine to be clean and sanitary at all times. He stated he did not know of any health risk the brown residue inside the ice machine may cause to a resident . The Administrator stated he did not think the sliced mandarin oranges stored inside the walk-in refrigerator in a tray needed to be covered since it was going to be served that afternoon. He did not think uncovered sliced oranges could cause any health risk to the residents . Record review of the facility policy, dated July 2014, reflected food shall be received and stored in a manner that complies with safe food handling practices. Food services or other designated staff will maintain clean food storage areas at all times. All food stored in refrigerator and freezer will be covered, labelled and dated.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #310, Resident #102, Resident #21, Resident #83, and Resident #68) of eight residents reviewed for infection control. 1. RN C failed to prevent cross contamination of Resident #310's Insulin pen when he placed a soiled glucometer next to the pen and then administered insulin to the resident with the soiled pen. 2. CNA B failed to perform hand hygiene during incontinence care for Resident #102. 3. The facility failed to prevent Resident #21's catheter bag, that was connected to her urostomy (an opening in the belly to redirect urine flow from the urinary system to the outside of the body), from contact with the floor. 4. MA D failed to sanitize the blood pressure cuff between uses on Resident # 83 and Resident # 68. Theses failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #310's face sheet, dated 01/24/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #310 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 01/10/24 at 11:00 a.m. revealed RN C placed a whole bottle of test strips, 2 lancets, 2 needles, 2 glucometers, and Residents #310's Novolog insulin Pen on a tray. RN C entered Resident #310's room and placed the tray of supplies on the resident's bedside table. RN C performed hand hygiene and put on gloves and performed a fingerstick blood sugar check. RN C then placed the soiled glucometer with the test strip still in place, next to the insulin pen on the tray. RN C removed his soiled gloves, performed hand hygiene, and left the room to go to the medication cart and determined the amount of insulin the resident required. RN C returned to the room performed hand hygiene and re-gloved. RN C picked up the insulin pen, that was still next to the soiled glucometer, and primed the pen and then dialed in 6 units of insulin and administered the insulin to Resident #310. RN C gathered the supplies and disposed of the lancet and needle in the sharp's container located in the resident's bathroom, and returned to the medication cart where he removed his gloves and performed hand hygiene, re-gloved and pulled out a germicidal wipe and wiped down the bottle of test strips, the insulin pen and both glucometers. In an interview with RN C on 01/14/24 at 11:20 a.m., he stated he carried in 2 glucometers and the whole bottle of strips in case one glucometer did not work or if he needed more test strips. He stated he should not have taken in the insulin pen and by placing the dirty glucometer next to the pen had potentially cross contaminated which could cause the risk of infection to the resident. He stated he should have only taken in the necessary supplies he needed to perform the fingerstick blood sugar test. Record review of RN C's competency checks, dated 12/19/23, reflected he was competent in administering subcutaneous injections and blood glucose monitoring. In an interview with the DON on 01/10/24 at 11:35 a.m., she stated performing fingerstick blood sugars and administering insulin was a two-step process. She stated staff were not following the facility procedure if they were carrying in multiple supplies to check a resident's blood sugars. She stated they were only to carry in the necessary supplies needed to check a blood sugar, then perform hand hygiene and retrieve the required insulin and perform hand hygiene before and after giving the insulin. She stated taking in the whole bottle of test strips which was used for multiple residents was not acceptable and by taking in the insulin pen and placing the used glucometer next to it cross contaminated the pen. She stated the staff were to complete the fingerstick monitoring and then proceed with the insulin administration if needed. She stated failing to follow the correct procedure placed residents at risk of cross contamination and infections. Record review of the facility's policy, Obtaining a Fingerstick Glucose level, dated October 2011, reflected .Assemble equipment and supplies needed .Obtain blood sample .Dispose of the lancet in the sharps disposal container .discard disposable supplies in the designated containers .Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .remove gloves and discard into designated container .Wash hands Record review of the facility's policy, Insulin Administration, dated September 2014, reflected .Wash hands .Check blood glucose per physician order or facility protocol .Remove Insulin vial from storage point .Select an injection site .Depress the plunger and remove the needle .dispose of the needle in a designated container .Wash hands 2. Record review of Resident #102's 5-day MDS assessment, dated 12/24/23, reflected a [AGE] year-old female with an admitted [DATE]. Resident #102 had a BIMs of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included diabetes and malignant neoplasm (cancer) of the right lung. Record review of Resident #102's care plan, dated 12/21/23, reflected . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent . An observation on 01/10/27 at 01:30 p.m. revealed CNA B entered Resident #102's room preparing to provide incontinence care. CNA B washed her hands, put on gloves, and unfastened Resident #105's brief to reveal the resident had been incontinent of urine. CNA B took a peri- wipe and cleaned the resident's perineal area, wiping from front to back and assisted the resident to roll on her side. CNA B took a peri-wipe and wiped each of the resident's buttocks from her lower back down toward the resident's labia. With the same gloves, CNA B applied barrier cream to a chafed area on the resident's right buttocks and then removed the soiled brief and placed a clean brief under the resident and rolled her back onto her back and fastened the brief. CNA B removed her gloves and washed her hands. In an interview with CNA B on 01/10/27 at 01:45 p.m., she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she should have changed her gloves after she cleaned the resident, before applying the barrier cream and clean brief. She stated failure to perform hand hygiene placed the resident at risk of infections. Record review of CNA B's skill checks dated 10/15/23 reflected she was competent in performing peri-care and hand hygiene. In an interview with the DON on 01/10/24 at 02:00 p.m., she stated staff were to change their gloves and perform hand hygiene after they performed incontinence care, before applying the barrier cream and clean brief. She stated by not following proper hand hygiene it placed residents at risk of urinary tract infections. Record review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated August 2013, reflected, .Employees must wash their hands .when hands are visibly dirty or soiled with blood or other body fluids .after removing gloves .before moving from a contaminated body site to a clean body site during resident care .after removing gloves 3. Record review of Resident #21's face sheet, dated 01/11/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21's relevant diagnoses included flaccid neuropathic bladder (the muscles of the bladder lose the ability to contract), obstructive and reflux uropathy (inability of the urine to flow causing the urine to flow back to the blader), and pyuria (pus in the urine). Record review of Resident #21's Quarterly MDS Assessment, dated 11/03/2023, reflected Resident #21 was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment also indicated the resident had an urostomy. Record review of Resident #21's Comprehensive Care Plan, dated 11/07/2023, reflected the resident had a urostomy bag (a pouch attached to the opening in the belly to collect the urine) related to neuromuscular dysfunction of bladder, flaccid neuropathic bladder, and obstructive and reflux uropathy. The interventions were to ensure the urinary catheter tubing was anchored and secure . the catheter bag related to when the resident moved around in the bed at times causing the catheter bag to dislodge or fall onto floor. Record review of Resident #21's Physician Order dated 08/25/2023 indicated, Urinary catheter ensure tubing anchor and privacy bag is intact and secure. Observation and interview with Resident #21 on 01/10/2024 at 9:07 a.m. revealed Resident #21 was on her bed, awake. Resident #21 had a catheter bag connected to her urostomy. The catheter bag was noted on the floor. Resident #21 stated she had a urostomy bag that was connected to a catheter bag. She said she had the urostomy and catheter bag set-up since the last quarter of the year. Resident #21 was advised her catheter bag was on the floor. Resident #21 stated the CNAs usually hooked the catheter bag on the side lowest part of the bed or on the knob of the last drawer of the right-side table. Observation and interview with LVN P on 01/10/2024 starting at 10:01 a.m., LVN E stated the proper care of the catheter was making sure it was off the floor. LVN P said the catheter bag should be off the floor because it would cause infection. LVN P added he would check Resident #21's catheter if it was still on the floor. LVN P went inside Resident #21's room and hooked the catheter bag on the railings below the bed. Interview with ADON H on 01/10/2024 at 12:25 p.m., ADON H stated the catheter bag should be off the floor. She said the catheter bag should be below the bladder but not on the floor. ADON H said it could cause infection especially for individuals who were immuno-compromised. ADON H said the expectation was for the staff to make sure the catheter bag was off the floor when the resident was on the bed or in the wheelchair. Interview with the DON on 01/10/2024 at 1:41 p.m., the DON stated the catheter bag should not be on the floor. The DON said it was an infection concern when the catheter bag was on the floor. The DON said if the catheter was on the floor, the catheter bag should be changed and hooked below the bladder. The DON said the nurses were responsible to ensure the catheter was off the floor. The DON added the nurse should start monitoring the catheter bag and should start reminding the staff that every time they would empty the catheter bag, they should hook it and make sure the catheter bag was off the floor. The DON said the expectation was the catheter bags would be off the floor to prevent infection and the staff would ensure they followed the best practice for catheter care. The DON concluded she would do an in-service regarding catheter bags not being on the floor and monitor the staff were doing a routine catheter care per shift. Interview with the Administrator on 01/10/2024 at 1:55 p.m., the Administrator stated the staff should have a conscious effort in preventing infection. The Administrator said the catheter bag should be off the floor to prevent a potential contamination. The Administrator said the expectation was for the staff to ensure the catheter was off the floor and the staff to monitor the catheter bag at the beginning of every shift and throughout their shift. Record review of the facility policy, Catheter Care, Urinary, revised January 3, 2023, reflected Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . 1. Use standard precautions when handling or manipulating the drainage system. 4. Record review of Resident #83's face sheet, dated 01/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included dementia and diabetes. Record review of Resident #68's face sheet, dated 01/11/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #68 had a diagnosis which included dementia. Observation during medication pass on 01/10/24 at 08:45 a.m. revealed MA D entered Resident #83's room to obtain her blood pressure. After performing the blood pressure reading MA D returned to the medication cart and obtained the resident's morning medications and administered them. MA D returned to the cart and walked to the next hall with the un-sanitized blood pressure cuff. MA D entered Resident #68's room and obtained her blood pressure without sanitizing the blood pressure cuff. MA D returned to the medication cart and obtained the resident's morning medications and administered them. MA D performed hand hygiene but did not sanitize the blood pressure cuff. In an interview with MA D on 01/10/24 at 9:20 a.m., she stated she was supposed to clean the blood pressure cuff with a germicidal wipe after each use. She stated she knew she was supposed to clean all the equipment between residents to prevent the spread of infection, she just forgot. In an interview with the DON on 01/10/24 at 11:20 a.m., she stated the staff were required to clean the equipment used after each use before using it on another resident. She stated failure to do this could potentially spread germs. Record review of the facility's policy titled, Cleaning, Disinfection of Resident-Care equipment, dated October 2018, reflected Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations .non-critical items are those that come in contact with intact skin but not mucous membranes .items include .blood pressure cuffs .Reusable resident care equipment will be decontaminated between residents according to manufacturer's' instructions 47743

Immediate Supervisor: [NAME] Alfafara Based on observation, interview, and record review, the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #72) reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer tubing was changed weekly as scheduled. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met. Findings include: Record review of Resident #72's face sheet, dated 01/10/24, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #72's relevant diagnoses which included atrial fibrillation (slow heartbeat) and chronic obstructive pulmonary disease (lung disease). Record review of Resident #72's Comprehensive MDS Assessment, dated 10/31/2023, reflected Resident #72's BIMS score was 13, which indicated the resident was cognitively intact. Resident #72's primary medical conditions were COPD and an unspecified cough. Record review of Resident #72's Care Plan, dated 11/05/2023, reflected the resident was care planned for COPD and one of the interventions was Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Record review of Resident #72's physician order, dated 01/15/2024, reflected, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML inhale orally every 6 hours as needed for SOB or Wheezing related to chronic obstructive pulmonary disease. In an observation on 01/09/24 at 10:49 AM of Resident #72's Nebulizer near her bed, revealed the tubing on the machine was dated 1-1-24. In an interview and observation on 01/09/24 at 01:15 PM with RN J in Resident #72's room. She was shown the tubing connected to Resident #72's Nebulizer, dated 1-1-24, and she stated the tubing should have been changed on 01/07/24 by the night nurse. She stated all tubing for respiratory machines were scheduled for changing every Sunday evening by the night nurse. She stated she was unsure why it was not done and not doing so could result in the resident getting an infection. RN J was observed changing out the tubing. In an interview on 01/11/24 at 10:30 AM with ADON H, she stated she was advised by RN J of Resident #72's tubing was not changed when scheduled, and she stated the tubing should have been changed on 01/07/24 by the Sunday night nurse. She stated all tubing for respiratory machines were changed out weekly on Sunday nights by the night nurse. She stated not changing the tubing as scheduled could result in the resident getting a respiratory infection. In an interview on 01/11/24 at 10:50 AM with the DON, she stated she was advised by ADON H of Resident #72's tubing not changed this past Sunday. She stated the tubing should have been changed on 01/07/24 by the Sunday night nurse. She stated that all tubing for respiratory machines were scheduled to be changed out weekly on Sunday nights by the night nurse. She stated she had already met with the ADON to in-service the weekend nurses of all scheduled required services for the residents, which included respiratory machine services. She stated not changing the tubing as scheduled could result in the resident getting a respiratory infection. Record review of the facility's Oxygen Administration, Policy/Procedure - Nursing Services, rev. 07/2022, reflected Policy: It is the policy of this facility that oxygen therapy is administered by licensed nurse as ordered by the physician . PURPOSE: The purpose of the oxygen therapy is to provide sufficient oxygen . will include: 1. That oxygen is to be administered; 2. When and how often oxygen is to be administered; 3. The type of oxygen device to use (i.e., mask, nasal). Oxygen concentrators should be cleaned according to manufacturer recommendations. Change or clean oxygen concentrator filters according to manufactures' recommendations.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Resident #59 and Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #59 and #77's rooms were in a position that was accessible to the residents. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings include: 1. Record review of Resident #59's face sheet, dated 01/10/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #59 had relevant diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (insufficient oxygen in the brain causing stroke) affecting the left non-dominant side, muscle weakness, and muscle wasting (loss of muscle mass due to weakness) and atrophy (decrease in size of muscle). Record review of Resident #59's quarterly MDS assessment, dated 12/19/2023, reflected the resident was cognitively intact with a BIMS score of 14. Resident #59 required one-person physical assist for bed mobility, transfer, eating, and toilet use. Record review of Resident #59's Comprehensive Care Plan, dated 01/02/2024, reflected the resident had an ADL self-care performance deficit related to disease process and one of the interventions was to encourage the resident to use bell to call for assistance. Observation on 01/09/2024 at 9:12 AM revealed Resident #59 was in her bed, resting. Resident #59's call light was on the floor between the bed and the left side table. A trash can half-filled was near the call light on the floor. Observation on 01/09/2024 at 1:23 PM revealed Resident #59 was in her bed, resting. Resident #59's call light was still on the floor between the bed and the left side table. The trash can beside the call light on the floor was empty. Observation and interview with Resident #59 on 01/10/2024 at 07:36 AM revealed the resident was in her bed, awake. Resident #59 stated to call for assistance she used the call light. Resident #59 searched for the call light at the left side of her bed but did not find it. Resident #59 said she could not find it. Resident #59 added she would wait for somebody to come to ask her if she needed something. Observation and interview with CNA G on 01/10/2024 at 7:36 AM, CNA G stated the call lights should always be within the reach of the residents. CNA G said the call lights were very important for the residents because the call lights were used by the residents to call the staff if they needed something or if they needed assistance. CNA G said if the residents did not have their call lights, the residents might fall trying to reach for the call light. Without the call lights, the needs of the residents would not be addressed. CNA G went back inside Resident #59's room and picked up the call light and clipped it near the resident. CNA G said all staff were responsible in ensuring call light were within reach of the residents. Interview with RN J on 01/10/2024 at 7:45 AM, RN J stated the residents used their call lights to let the staff know they needed assistance. RN J said without the call lights, the staff would not know if the residents needed the staff or were in need of something. She said the needs could be wanting to go to the bathroom or wanting to go out of the room. RN J added the residents might fall trying to get up to get the call light or trying to get somebody to help them. RN J added she would make a round to make sure the call lights were within the reach of the residents. RN J added all staff should monitor if the call light was with the residents. 2. Record review of Resident #77's face sheet, dated 01/04/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #77 had relevant diagnoses which included difficulty in walking, other abnormalities of gait and mobility, and muscle wasting. Record review of Resident #77's Quarterly MDS Assessment, dated 12/11/2023, reflected the resident was cognitively intact with had a BIMS score of 13. Resident #77 required one-person physical assist for bed mobility, transfer, eating, and toilet use. Record review of Resident #77's comprehensive care plan, dated 12/24/2023, reflected the resident had an ADL self-deficit performance deficit related to disease process and one of the interventions was to encourage the resident to use bell to call for assistance. Record review of Resident #77's Comprehensive Care Plan, dated 10/14/2023, reflected the resident had a high risk for fall related to impaired cognition, communication deficit, and actual fall. One of the interventions listed was to ensure resident's call light was within reach and encourage the resident to use the call light for assistance. Record review of Resident #77's Fall Risk Assessment, dated 12/09/2023, reflected the resident had a high risk for fall with a score of 8.0. Observation and interview with Resident #77 on 01/10/2024 at 9:15 AM revealed the resident was sitting on his recliner located on the right side of the bed. Resident #77's call light was hanging on the left side of the bed. Resident #77 said he was already old and walking a short distance could make him tired. The resident stated if he needed assistance from staff there was a cord with a red push button at the end. Resident #77 started to look for his call light on the bed and said the staff forgot to put it on top of the bed. Resident #77 added he would just wait for a staff to give him his call light. Observation and interview with CNA A on 01/10/2024 at 9:38 AM, CNA A stated the call lights were very important for the residents. She said residents used their call lights to call the staff if they needed some assistance or if they needed the nurse because they were not feeling well. CNA A added if the residents did not have their call lights, the residents might be frustrated or mad because they could not tell somebody they needed something. CNA A further said the residents could fall in the process of getting the call light or getting the things they needed. CNA A went inside Resident #77's room pulled the call light from the right side of the bed, and placed the call light on top of the bed where the resident could reach it. In an interview with LVN P on 01/10/2024 at 10:39 AM, LVN P stated he did not notice the call light was far from the resident when he checked on Resident #77. LVN P said the call lights must be within the reach of the residents at all times. LVN P said the call lights were used by the residents to call the attention of the staff if they needed something or if they needed help. LVN P said without the call lights, the staff would not know if the residents needed something, wanted to go to the bathroom, or had any discomfort. LVN P added the residents might fall trying to get the call light or trying to get somebody to help them. LVN P said he would go check on Resident #77 and see if the resident's call light was within his reach. In an interview with the DON on 01/10/2024 at 1:41 PM, the DON stated the call lights must be within reach of the residents at all times. The DON said the residents used the call lights as a means of communication with the staff. The DON added the residents used the call lights if they needed help or to alert the staff they were not feeling well. The DON stated a lot of things could happen if the call lights were not with the residents. The residents might try to get up on their own and fall on the process. The staff would not be able to attend to the resident's needs during emergencies. The DON said all the staff were responsible in placing the call lights within reach. The DON said all the staff must zoom in on every detail inside the room. The DON said monitoring call light placement should be done during department heads, during nurses' rounds, and during CNAs rounds. The DON said the expectation was for the staff to make sure the call lights were within the reach of the residents. The DON said she would make an in-service about the call lights and would ensure staff adherence to placing the call lights within the reach of the residents. Interview with the Administrator on 01/10/2024 at 1:55 PM, the Administrator stated the call lights should always be within the reach of the residents at all times because the call lights were their form of communication. The Administrator said there must be conscious efforts from the staff in making sure the call lights were with the residents so the needs of the residents were met. He said the expectation was call lights be with the residents at all times. Record review of the facility's policy Resident Call Light System, revised 6/2023, reflected Purpose: The purpose of this procedure is to respond to the resident's request and needs . General Guidelines . 4. Ensure that the call light is easily reachable by the resident.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #102) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #102 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #102's 5-day MDS assessment, dated 12/24/23, reflected a [AGE] year-old female with an admitted [DATE]. Resident #102 had a BIMs of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Her diagnoses included diabetes and malignant neoplasm (cancer) of the right lung. Record review of Resident #102's care plan, dated 12/21/23, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 01/10/27 at 01:30 p.m. revealed CNA B entered Resident #102's room preparing to provide incontinence care. CNA B washed her hands and put on gloves and unfastened Resident #105's brief to reveal the resident was incontinent of urine. CNA B took a peri-wipe and cleaned residents' perineal area, wiping from front to back and assisted the resident to roll on her side. CNA B took a peri-wipe and wiped each of the residents' buttocks from her lower back down toward the resident's labia. CNA B did not wipe the resident's rectal area, only her buttocks. With the same gloves, CNA B applied barrier cream to a chafed area on the residents' right buttocks and then removed the soiled brief and placed a clean brief under the resident and assisted her to roll back onto her back and fastened the brief. CNA B removed her gloves and washed her hands. Review of CNA B's skill checks dated 10/15/23 reflected she was competent in performing peri-care and hand hygiene. In an interview with CNA B on 03/01/23 at 10:15 a.m. she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she was supposed to clean the resident from front to back and then on her buttocks she was to clean from back to front. CNA B then stated she should have cleaned the resident's rectal area opposite of what she had done after she thought about it. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them a risk of infections. In an interview with DON on 01/10/24 at 02:00 p.m., she stated staff were to clean residents from front to back during incontinence care. She stated by not following proper peri care it placed residents at risk of urinary tract infections. Record review of the facility's policy titled, Perineal care, revised October 2010, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal are, wiping from front to back .Separate labia and wash area downward from front to back . Assist the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of three residents reviewed for quality of care related to change of condition and assessment. 1. RN C failed to schedule with the laboratory provider on [DATE] for a lab draw ordered for [DATE] (Saturday) for Resident #1. Due to the delay, the physician ordered labs were not drawn until [DATE]. 2. LVN D failed to assess Resident #1's for a significant change in condition, when CNA M alerted her on [DATE] that Resident #1 was not eating and on [DATE] when CNA's K and CNA L alerted her that Resident #1 was unable to eat or to sit up without staff support. As a result, Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 3:08 p.m. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she had potential for dehydration and Urinary tract infections related to diuretic therapy, swallowing problems and dementia. The interventions included to assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection) .Monitor labs as ordered, Notify MD of abnormalities .Monitor/document/report to MD PRN for s/sx of UTI .malaise .altered mental status .loss of appetite. Review of NP G's progress note dated [DATE] related to Resident #1, reflected, Reason for Visit: Nurse reported patient somnolent. Blood sugar 281 .Physical exam .lethargic .no wheezing .O2 saturation 98% on room air .Diagnoses: [REDACTED].Assessments/Plan .BMP (Basic Metabolic Panel) CBC (complete blood count) UA with C&S (urinalysis with culture and sensitivity) . Blood sugar elevated but continue current meds for now . Review of Resident #1's nurses note for [DATE] did not reveal any documentation of the resident's status, notification of family for change in resident's condition or follow up from NP G's assessment. Review of the physician's orders [REDACTED]. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - paper report could not be located. [DATE] - nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. [DATE]- nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. Interview with ADON A on [DATE] at 2:00 p.m. revealed she had not been able to locate the 24-hour report for [DATE]. Review of Resident #1's Nurse's notes from [DATE] to [DATE] reflected no documentation from any shift addressing Resident #1's status or attempts to obtain ordered labs. Review of Resident #1's Nurse's notes on [DATE] entered by RN C at 10:05 a.m. revealed, Change of condition. Notified MD about sob/increase respirations which started on [DATE]. See SBAR Review of Resident #1's SBAR- Change of Condition completed by RN C on [DATE] at 10:05 a.m. revealed, .The problem .I am calling about .sob/increased respirations .This started on: [DATE] .The problem .has gotten worse since it started .Other things that have occurred with this problem .decrease po intake .Most recent blood pressure: ,[DATE], Pulse 115- New irregular pulse, Respirations 20, most recent temp [AGE].5 most recent O2 sats: [AGE] %.Mental status .decrease level of consciousness .Respiratory evaluation .Shortness of breath, labored or rapid breathing .describe decrease appetite: No oral intake x 2 consecutive meals .decreased urinary output .Reported to: (NP G) on [DATE] at 9:45 a.m. Recommendations of Primary Clinician: Stat cxr (chest X-Ray) , UA with C&S, IV fluids send to ER for eval (evaluation). Date and time of family notification: [DATE] 11:00 a.m. Review of Resident #1's nurse's note on [DATE] entered by RN C at 1:01 p.m. revealed, Res (resident) noted to have low O2 stats this am upon initial rounds res 02 stats were [AGE] on r/a (room air) o2 applied per nasal cannula increased to 95% with 3 L (liters) of 02 call placed to NP to report change in condition new orders received for normal saline at 50 cc/hr x 1 L and stat cxr (chest X-Ray) upon reassessing res O2 stats noted to have dropped to [AGE]% O2 increased to 5 L with mask O2 stats remained the same 911 called for transport to ( hospital name) rp (representative) called and notified of transport and res current condition. Review of the Resident #1's lab results report dated [DATE] reflected, collected date/time [DATE] 3:00 a.m. Resulted date/time: [DATE] 6:39 p.m. Order comments: Critical BUN, Creatinine, and [MED] called to RN S on [DATE] at 6:38 p.m. [MED] 1[AGE] CH (critical high) Ref Range- ,[DATE] .BUN 144 CH Ref Range ,[DATE] .Creatinine 8.1 CH Ref Range 0XXX,[DATE]. 2. Urinalysis report reflected .WBC (white blood cells) 99 ref range-,[DATE] .Bacteria .Moderate . Interview with NP G on [DATE] at 11:30 a.m. revealed BUN and Creatinine levels as high as Resident #1's were indicative of [MEDICAL CONDITION]. She stated Resident #1's elevated [MED] level would be indicative of dehydration. Review of the facility's laboratory request binder revealed the following undated notice in the front of the binder, .Weekend Policy .(Lab Name) provides daily route service Monday through Friday .No routine draws will be collected on the weekends .Scheduling of necessary Saturday draws must be called into the laboratory .Scheduling of necessary Sunday draws must be called into the laboratory .As always (Lab Name) provides around the clock STAT service for critical patients . Review of Resident #1's Hospital Physician consultation report dated [DATE] reflected: .Reason for admission: Septic Shock .I saw the patient in the Emergency Department, at which point, she was noted to be unresponsive with rattling breath sounds audible. Systolic blood pressure was 68, pulse oximetry was 92%.Mucous membranes were dry .Laboratory studies were notable as mention in the HPI for [MED] of 181, potassium of 7.0, BUN and creatinine of 137 and 8.8. [MEDICATION NAME] was 7.3. More than 100 WBC's on UA with a white blood cell count of 20 .It appears, based on her physical exam, review of her hemodynamics, and laboratory studies, that the patient has a high risk of mortality. The patient has an out of hospital Do Not Resuscitate. Hence, palliative care was involved fairly urgently . Review of Resident #1's Hospital Nurse's notes reflected, on [DATE] at 11:11 a.m. Resident #1 arrived by E[CONDITION]. Presenting complaint: E[CONDITION] states patient coming from (facility name). Patient is normally responsive per staff. Staff reports patient not eating or drinking weak for several days. Staff called 911 because patients sat decreased to 70's and patient was unresponsive and appears to be struggling to breath. BP ,[DATE], then ,[DATE] .3:30 p.m. Patient expired. Time of death 2:30 p.m. An interview with RN C on [DATE] at 10:30 p.m. revealed she was Resident #1's charge nurse 6:00 a.m. to 2:00 p.m. on [DATE] and [DATE]. She said on [DATE] Resident #1 had been on a slow decline. She was not as responsive as usual but was still eating some. She stated when NP G came in that day, [DATE], she asked her to assess Resident #1. She stated NP G evaluated the resident and ordered labs and a UA to rule out UTI to be completed by [DATE]. She stated it was around the end of her shift, so she put the orders in the computer system, and placed the lab requisition in the laboratory binder and placed a copy of the order on top of the 24-hour report clip board. She stated she communicated with oncoming staff about the Resident #1's condition but did not remember if she put anything on the 24-hour report. She stated she did not call the family about the resident's decline or the treatments ordered. She stated she worked Monday through Friday, and when she returned on [DATE], LVN E stated the resident's labs were drawn early that morning, but he had not been able to get a UA. She stated after she made rounds around 6:30 a.m. to 7:00 a.m. she noted the resident's O 2 sats were low, so she put her on O2 and they came back up. She stated she finished her rounds and called NP G around 8:,[DATE]:30 a.m. She stated the NP ordered stat chest X-Ray and UA. She stated she obtained the UA and called the laboratory for pick up and ordered the X-Ray. She stated she attempted to feed the resident who was unable to take anything by mouth. LVN E stated she called the NP back around 9:00 a.m. to 9:30 a.m. to tell her about Resident #1's decreased PO intake and received an order for [REDACTED]. She stated she was not aware she had to call the laboratory to have labs drawn on the weekends, since she worked Monday through Friday. She stated she should have documented on a SBAR when she had the NP check on the resident on [DATE], which would have prompted her to call the family, and start a follow up process in the record. Interview with LVN E on [DATE] at 2:04 p.m. revealed he had worked from 10:00 p.m. to 6:00 a.m. on [DATE], [DATE] and [DATE]. He stated he was not aware of any lab requests for Resident #1 until the lab technician came in around 3:00 a.m. on [DATE] to do routine labs. He stated the lab technician had told him there was a request for a UA for Resident #1. He stated he went and attempted to get the UA but was unable to obtain. LVN E stated he told the oncoming nurse that the UA had not been done. He stated he should have documented his attempts in the progress note and placed it on the 24-hour report but failed to do so. He stated Resident #1 slept most of the night and he was unaware of any change in condition. Interview with NP G on [DATE] at 11:25 a.m. revealed the nursing staff had alerted her on [DATE] that Resident #1 was lethargic. She stated the resident would present with a blank gaze when she was getting a UTI, so that was why she had ordered the labs. She stated she had told the nurse to have them drawn by [DATE]. She stated she was not aware routine labs were not drawn on the weekends, otherwise she would have ordered it stat for [DATE]. She stated the facility called her Monday, [DATE], about Resident #1's O2 sats, but stated her vitals were ok. She stated she had not seen the lab results that were done, but when she heard the lab values, she stated it appeared the resident was in [MEDICAL CONDITION], and she would have sent her to the ER immediately. She stated she expected the nurses to use nursing judgement, and not wait to call her before sending a resident to ER if their condition continued to worsen. Interview with LVN D on [DATE] at 12:00 p.m. revealed she was the Charge Nurse responsible for Resident #1 on [DATE] and [DATE] from 6:00 a.m. to 10:00 p.m. She stated she was unaware Resident #1 had an order for [REDACTED]. She stated Resident #1 was alright on [DATE], but on [DATE] the CNAs told her they did not want to get Resident #1 up, because she was not doing very well. She stated she told the aides they had to get Resident #1 up, because the family insisted she be gotten up for all meals. She stated the CNAs got her up and took her to breakfast, but after about 30 minutes they had to lay her back down because she was leaning in her chair. LVN D stated she fed Resident #1 once they got her back to bed. She stated she did not think there was anything unusual about the resident, stating her vital signs were OK. Interview with CNA K on [DATE] at 1:15 p.m. revealed she worked 6:00 a.m. to 2:00 p.m. on [DATE], [DATE] and [DATE]. She stated Resident #1 did not eat or drink anything for her over the weekend and she had notified LVN D. She stated they were concerned about getting Resident #1 up since she was so weak, but the nurse insisted they get her up. She stated once they got her up, the resident could not hold herself up in the wheelchair and they had to hold her to keep from falling forward. She stated the resident could not swallow any fluids. Interview with CNA L on [DATE] at 1:25 p.m. revealed she worked 6:00 a.m. to 2:00 p.m. on [DATE], [DATE], and [DATE]. She stated Resident #1 was not doing very well on Saturday, [DATE], stating she was just not herself and was not very responsive. CNA L stated she was worse on Sunday [DATE]. She stated she had observed CNA K trying to get her to eat, and stated she had to hold the resident up in the wheelchair to keep her from falling out. She stated she stayed with the resident while CNA K went to get the nurse. She stated when LVN D came and saw Resident #1, she stated, she needed to go back to bed. CNA L stated she and LVN D put the resident back to bed. She stated the resident was not short of breath, but she sounded a little raspy. She stated the resident did not always eat well but would always drink fluid. CNA L stated that day the fluids would run right back out of her mouth. She stated had RN C been here over the weekend, she felt like she would have sent her to the hospital. Interview with CNA M on [DATE] at 2:40 p.m. revealed she had worked the 2:00 p.m. to 10:00 p.m. shift on [DATE], [DATE] and [DATE]. She stated she had attempted to feed Resident #1 on Friday, [DATE], and she could not get her to open her eyes or her mouth. She stated she reported to LVN F, who told her she would go and check on her. CNA M stated she did not feed her on Saturday, [DATE], or Sunday, [DATE]. She stated Resident #1 usually would drink for her and eat her sweets, but she had not been able to get her to eat or drink. She stated Resident #1 was not her usual self. Interview with LVN F on [DATE] at 2:55 p.m. revealed she was the Charge Nurse on 2:00 p.m. to 10:00 p.m. shift on [DATE] and had fed Resident #1. She stated she was not aware of any lab request that had been made and did not note any change in her condition on her shift. Interview with Resident #1's MD on [DATE] at 11:48 a.m. revealed he was not made aware of Resident #1's worsening condition until [DATE]. He stated he had not been informed about the laboratory results, or the delay in obtaining the lab results. Once informed what the lab results were, he stated Resident #1 would have been immediately hospitalized . He stated he was unaware routine labs were not being drawn over the weekend and he thought they had already addressed the issue in the past. He stated he thought that was why the facility had changed lab services. He stated his expectation when he ordered labs, was for them to be done within ,[DATE] hours unless he ordered them stat, then they would need to be done sooner. Interview with the DON on [DATE] at 11:00 a.m. revealed the facility's lab procedure for routine labs were Monday through Friday, unless the staff called the lab to let them know of a request for the weekend. She stated stat orders must always be called in. She stated the staff was supposed to place the requisition in the lab binder once the lab was called and the order was written and then placed on the 24-hour report for follow up. She stated the staff was also expected to do a SBAR on any change of condition, which triggered them to call the MD, family and required follow up. Interview with Resident #1's family member on [DATE] at 05:23 p.m. revealed she went to the facility to speak with the DON about the fact they received a call right before the resident was sent to the hospital and had not been informed from the facility about the condition the resident was in. She stated she told the DON only one family member was able to make it to the hospital in time to say goodbye, before the resident passed away. She stated the DON apologized and made excuses. She stated she had not received any follow up call from the facility related to her complaint. An interview with the DON on [DATE] at 10:10 a.m. revealed Resident #1's family came to the facility on [DATE] upset the facility had not notified them earlier or indicated how bad the resident was. She also had stated the family member had said resident had a UTI and the resident was supposed to be getting routine UA with C&S and wanted to know why she had not been receiving that. The DON stated she informed the family member that routine UA's were not customary, and it required a physician order [REDACTED]. The DON stated she did not review the resident's record, nor did she interview any of the staff. She stated not long after the family came in, she had another issue come up and did not go back and review Resident #1's record. In a follow up interview with the DON on [DATE] at 9:00 a.m. she stated she had learned a valuable lesson from this incident, and stated had she investigated the grievance, reviewed the resident's record and talked with the staff, she would have been aware of the communication breakdown and the staff's failure to address the resident's change in condition. She stated moving forward that would be the expectation. She stated when she did disciplinary action on RN C she readily admitted her failings and was aware going forward of the expectations. She stated when she did disciplinary action on LVN D, she continued to insist she did not see a change in condition for Resident #1. Based on this, the decision to terminate LNV D was made. The DON stated she also received a disciplinary warning for her failure to investigate the grievance. Review of a Disciplinary Action Form, dated [DATE], reflected LVN D was terminated due to failure to follow policy and procedure for change of condition. Review of a Disciplinary Action Form, dated [DATE], reflected the DON received a written warning for failure to follow policy and procedure grievances. Review of a Disciplinary Action Form, dated [DATE], reflected RN C received a written warning for failure to follow policy and procedure for change of condition and laboratory procedures. Review of the facility's policy, Request for Diagnostic Services, dated [DATE], reflected, .All requests for diagnostic services must be ordered by the resident's Attending Physician .Orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED]. Review of the facility's policy, Change in a Resident's Condition or Status, dated [DATE], reflected Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending physician .when there has been.A significant change in resident's physical/emotional/mental condition. The Nurse Supervisor/Charge Nurse will notify the resident's family or representative .when there has been.A significant change in resident's physical/emotional/mental condition.The nurse supervisor/charge nurse will be record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . An IJ was identified on [DATE]. The Administrator and DON were notified of the IJ on [DATE] at 3:08 p.m. and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator on [DATE] at 3:07 p.m. revealed she believed the IJ occurred due to lack of communication which started with RN C's failure to follow the procedure for requesting labs. The Administrator said to prevent further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation, laboratory procedures and Nurse Management rounding procedures seven days a week. She stated the facility would be having a QAPI Committee meeting with the Medical Director to review interventions, to identify root causes and to provide direction of identified areas of concern. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Steps Facility implemented the following Action Plan that affected Resident #1 and has the potential to affect other residents . 2. Employee RN C received disciplinary action for failure to follow lab policy and procedure. 3. Employee LVN D received disciplinary action for failure to notify patient change of condition and was terminated. 4. DON received disciplinary action and in-service on grievance policy. 5. DON and the ADON A and ADON B were in-serviced by the Administrator on rounding on patients on change of condition log and monitoring the 24-hour report and SBAR 6. The Administrator and DON were in-serviced on Abuse and Neglect by the RDO. 7. DON/ADON audited lab orders for discrepancies. No discrepancies noted. 8. Rounds completed on residents, chart reviews completed. Audited all labs facility wide. No discrepancies. 9. Medical directors notified Completion date of these actions was [DATE] In Service Education The following in services were provided to staff on ,[DATE] and [DATE] 1. Nursing staff, physicians and physician extenders on Lab policy and Procedures 2. Nursing staff on Change of Condition and protocol 3. Nursing staff on SBAR 4. All staff abuse and neglect Nursing staff will not be allowed to work their shifts until they complete the assigned in-services. Monitoring Administrator/DON have implemented the following systems of monitoring; 1. ADONS will audit lab orders each day and compare to the service log. The charge nurse is responsible for completing the service log: see attached service log which includes patient name, ordered test, collection time, draw site, comments, result received, physician notified. It also includes lab rep and nurse signature lines. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 2. Nursing staff to notify DON/ADON on all changes of condition during business hours and document on change of condition log. After hours the charge nurse will notify the DON/ADON on call via on call phone and document on change of condition log. 3. DON/ADON will complete morning start up reviewing the 24-hour report daily to insure the following are documented appropriately and accurately completed: a. change of condition log b. lab service log c. x-ray orders d. new orders e. SBAR They will round on patients with changes of condition, review their charts and 24-hour report. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 4. These systems were implemented [DATE]. Monitoring of the plan of removal included: Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Changes of condition - who to report to, things to mention, who to notify, how to document. Lab Ordering process and Lab follow up On [DATE] individual staff interviews were conducted with RN C, LVN I, RN J, RN N, ADON B, LVN F, and LVN O from 1:40 p.m. to 3:00 p.m. On [DATE] individual staff interviews were conducted with RN P, RN Q, LVN R and ADON A from 9:20 a.m. to 9:55 a.m. Staff represented all three shifts including double weekends and PRN staff. Staff were asked to describe the training they had received. All employees interviewed were able to correctly answer questions and described all changes of conditions that would be reported to the Supervisor, MD and family. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. All staff were aware of the laboratory procedure. On [DATE] from 8:30 a.m. to 10:15 a.m. four individual residents (Resident #2, #3, #4 and #5) were reviewed for recent changes of condition. All residents reviewed had an SBAR completed with description of the change of condition, notification of the MD with follow up orders and lab request, assessment of the resident and notification of family. On [DATE] at 10:30 a.m. the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #1) of three residents reviewed for labs and cultures. The facility failed to ensure Resident #1's labs were obtained as ordered and the physician was promptly notified of lab results due to a two-day delay in obtaining labs. As a result, Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 3:08 p.m. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she had potential for dehydration and Urinary tract infections related to diuretic therapy, swallowing problems and dementia. The interventions included to assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection) .Monitor labs as ordered, Notify MD of abnormalities .Monitor/document/report to MD PRN for s/sx of UTI .malaise .altered mental status .loss of appetite. Review of NP G's progress note dated [DATE] related to Resident #1, reflected, Reason for Visit: Nurse reported patient somnolent. Blood sugar 281 .Physical exam .lethargic .no wheezing .O2 saturation 98% on room air .Diagnoses: [REDACTED].Assessments/Plan .BMP (Basic Metabolic Panel) CBC (complete blood count) UA with C&S (urinalysis with culture and sensitivity) . Blood sugar elevated but continue current meds for now . Review of the physician's orders [REDACTED]. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - paper report could not be located. [DATE] - nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. [DATE]- nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. Review of Resident #1's Nurse's notes from [DATE] to [DATE] reflected no documentation from any shift addressing Resident #1's status or attempts to obtain ordered labs. Review of Resident #1's SBAR- Change of Condition completed by RN C on [DATE] at 10:05 a.m. revealed, .The problem .I am calling about .sob/increased respirations .This started on: [DATE] .The problem .has gotten worse since it started .Other things that have occurred with this problem .decrease po intake .Most recent blood pressure: ,[DATE], Pulse 115- New irregular pulse, Respirations 20, most recent temp [AGE].5 most recent O2 sats: [AGE] %.Mental status .decrease level of consciousness .Respiratory evaluation .Shortness of breath, labored or rapid breathing .describe decrease appetite: No oral intake x 2 consecutive meals .decreased urinary output .Reported to: (NP G) on [DATE] at 9:45 a.m. Recommendations of Primary Clinician: Stat cxr (chest X-Ray) , UA with C&S, IV fluids send to ER for eval (evaluation). Date and time of family notification: [DATE] 11:00 a.m. Review of Resident #1's nurse's note on [DATE] entered by RN C at 1:01 p.m. revealed, Res (resident) noted to have low O2 stats this am upon initial rounds res 02 stats were [AGE] on r/a (room air) o2 applied per nasal cannula increased to 95% with 3 L (liters) of 02 call placed to NP to report change in condition new orders received for normal saline at 50 cc/hr x 1 L and stat cxr (chest X-Ray) upon reassessing res O2 stats noted to have dropped to [AGE]% O2 increased to 5 L with mask O2 stats remained the same 911 called for transport to ( hospital name) rp (representative) called and notified of transport and res current condition. Review of the Resident #1's lab results report dated [DATE] reflected, collected date/time [DATE] 3:00 a.m. Resulted date/time: [DATE] 6:39 p.m. Order comments: Critical BUN, Creatinine, and [MED] called to RN S on [DATE] at 6:38 p.m. [MED] 1[AGE] CH (critical high) Ref Range- ,[DATE] .BUN 144 CH Ref Range ,[DATE] .Creatinine 8.1 CH Ref Range 0XXX,[DATE]. 2. Urinalysis report reflected .WBC (white blood cells) 99 ref range-,[DATE] .Bacteria .Moderate . Interview with NP G on [DATE] at 11:30 a.m. revealed BUN and Creatinine levels as high as Resident #1's were indicative of [MEDICAL CONDITION]. She stated Resident #1's elevated [MED] level would be indicative of dehydration. Review of the facility's laboratory request binder revealed the following undated notice in the front of the binder, .Weekend Policy .(Lab Name) provides daily route service Monday through Friday .No routine draws will be collected on the weekends .Scheduling of necessary Saturday draws must be called into the laboratory .Scheduling of necessary Sunday draws must be called into the laboratory .As always (Lab Name) provides around the clock STAT service for critical patients . Review of Resident #1's Hospital Physician consultation report dated [DATE] reflected: .Reason for admission: Septic Shock .I saw the patient in the Emergency Department, at which point, she was noted to be unresponsive with rattling breath sounds audible. Systolic blood pressure was 68, pulse oximetry was 92%.Mucous membranes were dry .Laboratory studies were notable as mention in the HPI for [MED] of 181, potassium of 7.0, BUN and creatinine of 137 and 8.8. [MEDICATION NAME] was 7.3. More than 100 WBC's on UA with a white blood cell count of 20 .It appears, based on her physical exam, review of her hemodynamics, and laboratory studies, that the patient has a high risk of mortality. The patient has an out of hospital Do Not Resuscitate. Hence, palliative care was involved fairly urgently . Review of Resident #1's Hospital Nurse's notes reflected, on [DATE] at 11:11 a.m. Resident #1 arrived by E[CONDITION]. Presenting complaint: E[CONDITION] states patient coming from (facility name). Patient is normally responsive per staff. Staff reports patient not eating or drinking weak for several days. Staff called 911 because patients sat decreased to 70's and patient was unresponsive and appears to be struggling to breath. BP ,[DATE], then ,[DATE] .3:30 p.m. Patient expired. Time of death 2:30 p.m. An interview with RN C on [DATE] at 10:30 p.m. revealed she was Resident #1's charge nurse 6:00 a.m. to 2:00 p.m. on [DATE] and [DATE]. She said on [DATE] Resident #1 had been on a slow decline. She was not as responsive as usual but was still eating some. She stated when NP G came in that day, [DATE], she asked her to assess Resident #1. She stated NP G evaluated the resident and ordered labs and a UA to rule out UTI to be completed by [DATE]. She stated it was around the end of her shift, so she put the orders in the computer system, and placed the lab requisition in the laboratory binder and placed a copy of the order on top of the 24-hour report clip board. She stated she communicated with oncoming staff about the Resident #1's condition but did not remember if she put anything on the 24-hour report. She stated she worked Monday through Friday, and when she returned on [DATE], LVN E stated the resident's labs were drawn early that morning, but he had not been able to get a UA. She stated she finished her rounds and called NP G around 8:,[DATE]:30 a.m. She stated the NP ordered stat chest X-Ray and UA. She stated she obtained the UA and called the laboratory for pick up and ordered the X-Ray. She stated she attempted to feed the resident who was unable to take anything by mouth. LVN E stated she called the NP back around 9:00 a.m. to 9:30 a.m. to tell her about Resident #1's decreased PO intake and received an order for [REDACTED]. She stated she was not aware she had to call the laboratory to have labs drawn on the weekends, since she worked Monday through Friday. She stated she should have documented on a SBAR when she had the NP check on the resident on [DATE], which would have prompted her to call the family, and start a follow up process in the record. Interview with LVN E on [DATE] at 2:04 p.m. revealed he had worked from 10:00 p.m. to 6:00 a.m. on [DATE], [DATE] and [DATE]. He stated he was not aware of any lab requests for Resident #1 until the lab technician came in around 3:00 a.m. on [DATE] to do routine labs. He stated the lab technician had told him there was a request for a UA for Resident #1. He stated he went and attempted to get the UA but was unable to obtain. LVN E stated he told the oncoming nurse that the UA had not been done. He stated he should have documented his attempts in the progress note and placed it on the 24-hour report but failed to do so. He stated Resident #1 slept most of the night and he was unaware of any change in condition. Interview with NP G on [DATE] at 11:25 a.m. revealed the nursing staff had alerted her on [DATE] that Resident #1 was lethargic. She stated the resident would present with a blank gaze when she was getting a UTI, so that was why she had ordered the labs. She stated she had told the nurse to have them drawn by [DATE]. She stated she was not aware routine labs were not drawn on the weekends, otherwise she would have ordered it stat for [DATE]. She stated the facility called her Monday, [DATE], about Resident #1's O2 sats, but stated her vitals were ok. She stated she had not seen the lab results that were done, but when she heard the lab values, she stated it appeared the resident was in [MEDICAL CONDITION], and she would have sent her to the ER immediately. She stated she expected the nurses to use nursing judgement, and not wait to call her before sending a resident to ER if their condition continued to worsen. Interview with LVN D on [DATE] at 12:00 p.m. revealed she was the Charge Nurse responsible for Resident #1 on [DATE] and [DATE] from 6:00 a.m. to 10:00 p.m. She stated she was unaware Resident #1 had an order for [REDACTED]. She stated Resident #1 was alright on [DATE], but on [DATE] the CNAs told her they did not want to get Resident #1 up, because she was not doing very well. She stated she told the aides they had to get Resident #1 up, because the family insisted she be gotten up for all meals. She stated the CNAs got her up and took her to breakfast, but after about 30 minutes they had to lay her back down because she was leaning in her chair. LVN D stated she fed Resident #1 once they got her back to bed. She stated she did not think there was anything unusual about the resident, stating her vital signs were OK. Interview with CNA L on [DATE] at 1:25 p.m. revealed she worked 6:00 a.m. to 2:00 p.m. on [DATE], [DATE], and [DATE]. She stated Resident #1 was not doing very well on Saturday, [DATE], stating she was just not herself and was not very responsive. CNA L stated she was worse on Sunday [DATE]. She stated she had observed CNA K trying to get her to eat, and stated she had to hold the resident up in the wheelchair to keep her from falling out. She stated she stayed with the resident while CNA K went to get the nurse. She stated when LVN D came and saw Resident #1, she stated, she needed to go back to bed. CNA L stated she and LVN D put the resident back to bed. She stated the resident was not short of breath, but she sounded a little raspy. She stated the resident did not always eat well but would always drink fluid. CNA L stated that day the fluids would run right back out of her mouth. She stated had RN C been here over the weekend, she felt like she would have sent her to the hospital. Interview with CNA M on [DATE] at 2:40 p.m. revealed she had worked the 2:00 p.m. to 10:00 p.m. shift on [DATE], [DATE] and [DATE]. She stated she had attempted to feed Resident #1 on Friday, [DATE], and she could not get her to open her eyes or her mouth. She stated she reported to LVN F, who told her she would go and check on her. CNA M stated she did not feed her on Saturday, [DATE], or Sunday, [DATE]. She stated Resident #1 usually would drink for her and eat her sweets, but she had not been able to get her to eat or drink. She stated Resident #1 was not her usual self. Interview with LVN F on [DATE] at 2:55 p.m. revealed she was the Charge Nurse on 2:00 p.m. to 10:00 p.m. shift on [DATE] and had fed Resident #1. She stated she was not aware of any lab request that had been made and did not note any change in her condition on her shift. Interview with Resident #1's MD on [DATE] at 11:48 a.m. revealed he was not made aware of Resident #1's worsening condition until [DATE]. He stated he had not been informed about the laboratory results, or the delay in obtaining the lab results. Once informed what the lab results were, he stated Resident #1 would have been immediately hospitalized . He stated he was unaware routine labs were not being drawn over the weekend and he thought they had already addressed the issue in the past. He stated he thought that was why the facility had changed lab services. He stated his expectation when he ordered labs, was for them to be done within ,[DATE] hours unless he ordered them stat, then they would need to be done sooner. Interview with the DON on [DATE] at 11:00 a.m. revealed the facility's lab procedure for routine labs were Monday through Friday, unless the staff called the lab to let them know of a request for the weekend. She stated stat orders must always be called in. She stated the staff was supposed to place the requisition in the lab binder once the lab was called and the order was written and then placed on the 24-hour report for follow up. She stated the staff was also expected to do a SBAR on any change of condition, which triggered them to call the MD, family and required follow up. Interview with ADON A on [DATE] at 11:40 a.m. revealed the nursing staff receives training about facility procedures such as lab services during their three day one on one training with an assigned staff member. She stated they all she should be aware of the lab procedure. Interview with LVN H on [DATE] at 11:45 a.m. revealed she always calls the lab when she has a lab order, because that is what she had been used to doing from another facility. She stated she does not recall if this facility had reviewed lab procedures with her or not. Interview with RN J on [DATE] at 11:50 p.m. stated she knew that the lab had to be called on the weekends because she had worked with this lab at another facility and knew the process. She stated she was not sure if she was told this at this facility or not. Interview with LVN I on [DATE] at 11:55 a.m. stated she does not work the weekends, so she was not the familiar with the weekend lab process. She stated she does not remember being told anything specific about lab procedures. Interview with Resident #1's family member on [DATE] at 05:23 p.m. revealed she went to the facility to speak with the DON about the fact they received a call right before the resident was sent to the hospital and had not been informed from the facility about the condition the resident was in. She stated she told the DON only one family member was able to make it to the hospital in time to say goodbye, before the resident passed away. She stated the DON apologized and made excuses. She stated she had not received any follow up call from the facility related to her complaint. In a follow up interview with the DON on [DATE] at 9:00 a.m. she stated she had learned a valuable lesson from this incident, and stated had she investigated the grievance, reviewed the resident's record and talked with the staff, she would have been aware of the communication breakdown and the staff's failure to address the resident's change in condition. She stated moving forward that would be the expectation. She stated when she did disciplinary action on RN C she readily admitted her failings and was aware going forward of the expectations. She stated when she did disciplinary action on LVN D, she continued to insist she did not see a change in condition for Resident #1. Based on this, the decision to terminate LNV D was made. The DON stated she also received a disciplinary warning for her failure to investigate the grievance. Review of the facility's policy, Request for Diagnostic Services, dated [DATE], reflected, .All requests for diagnostic services must be ordered by the resident's Attending Physician .Orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED]. An IJ was identified on [DATE]. The Administrator and DON were notified of the IJ on [DATE] at 3:08 p.m. and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator on [DATE] at 3:07 p.m. revealed she believed the IJ occurred due to lack of communication which started with RN C's failure to follow the procedure for requesting labs. The Administrator said to prevent further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation, laboratory procedures and Nurse Management rounding procedures seven days a week. She stated the facility would be having a QAPI Committee meeting with the Medical Director to review interventions, to identify root causes and to provide direction of identified areas of concern. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Steps Facility implemented the following Action Plan that affected Resident #1 and has the potential to affect other residents . 2. Employee RN C received disciplinary action for failure to follow lab policy and procedure. 3. Employee LVN D received disciplinary action for failure to notify patient change of condition and was terminated. 4. DON received disciplinary action and in-service on grievance policy. 5. DON and the ADON A and ADON B were in-serviced by the Administrator on rounding on patients on change of condition log and monitoring the 24-hour report and SBAR 6. The Administrator and DON were in-serviced on Abuse and Neglect by the RDO. 7. DON/ADON audited lab orders for discrepancies. No discrepancies noted. 8. Rounds completed on residents, chart reviews completed. Audited all labs facility wide. No discrepancies. 9. Medical directors notified Completion date of these actions was [DATE] In Service Education The following in services were provided to staff on ,[DATE] and [DATE] 1. Nursing staff, physicians and physician extenders on Lab policy and Procedures 2. Nursing staff on Change of Condition and protocol 3. Nursing staff on SBAR 4. All staff abuse and neglect Nursing staff will not be allowed to work their shifts until they complete the assigned in-services. Monitoring Administrator/DON have implemented the following systems of monitoring; 1. ADONS will audit lab orders each day and compare to the service log. The charge nurse is responsible for completing the service log: see attached service log which includes patient name, ordered test, collection time, draw site, comments, result received, physician notified. It also includes lab rep and nurse signature lines. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 2. Nursing staff to notify DON/ADON on all changes of condition during business hours and document on change of condition log. After hours the charge nurse will notify the DON/ADON on call via on call phone and document on change of condition log. 3. DON/ADON will complete morning start up reviewing the 24-hour report daily to insure the following are documented appropriately and accurately completed: a. change of condition log b. lab service log c. x-ray orders d. new orders e. SBAR They will round on patients with changes of condition, review their charts and 24-hour report. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 4. These systems were implemented [DATE]. Monitoring of the plan of removal included: Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Changes of condition - who to report to, things to mention, who to notify, how to document. Lab Ordering process and Lab follow up On [DATE] individual staff interviews were conducted with RN C, LVN I, RN J, RN N, ADON B, LVN F, and LVN O from 1:40 p.m. to 3:00 p.m. On [DATE] individual staff interviews were conducted with RN P, RN Q, LVN R and ADON A from 9:20 a.m. to 9:55 a.m. Staff represented all three shifts including double weekends and PRN staff. Staff were asked to describe the training they had received. All employees interviewed were able to correctly answer questions and described all changes of conditions that would be reported to the Supervisor, MD and family. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. All staff were aware of the laboratory procedure. On [DATE] from 8:30 a.m. to 10:15 a.m. four individual residents (Resident #2, #3, #4 and #5) were reviewed for recent changes of condition. All residents reviewed had an SBAR completed with description of the change of condition, notification of the MD with follow up orders and lab request, assessment of the resident and notification of family. On [DATE] at 10:30 a.m. the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for notification of changes. 1. RN C failed to notify Resident #1's responsible party of the resident's altered mental status on [DATE]. 2. LVN D failed to assess and notify Resident #1's physician and responsible party of a significant change in condition for Resident #1, when CNA M alerted her on [DATE] that Resident #1 was not eating and on [DATE] when CNA K and CNA L alerted her that Resident #1 was unable to eat or sit up without staff support. As a result, Resident #1 was hospitalized on [DATE] with [DIAGNOSES REDACTED]. Resident #1 expired in the hospital on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received and signed the IJ template on [DATE] at 3:08 p.m. These failures could place residents at risk for a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #1's Minimum Data Set (MDS) Quarterly Resident Assessment, dated [DATE], reflected she was a [AGE] year old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She had severe cognitive impairment and required extensive assistance of one person for her activities of daily living. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she had potential for dehydration and Urinary tract infections related to diuretic therapy, swallowing problems and dementia. The interventions included to assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection) .Monitor labs as ordered, Notify MD of abnormalities .Monitor/document/report to MD PRN for s/sx of UTI .malaise .altered mental status .loss of appetite. Review of NP G's progress note dated [DATE] related to Resident #1, reflected, Reason for Visit: Nurse reported patient somnolent. Blood sugar 281 .Physical exam .lethargic .no wheezing .O2 saturation 98% on room air .Diagnoses: [REDACTED].Assessments/Plan .BMP (Basic Metabolic Panel) CBC (complete blood count) UA with C&S (urinalysis with culture and sensitivity) . Blood sugar elevated but continue current meds for now . Review of Resident #1's nurses note for [DATE] did not reveal any documentation of the resident's status, notification of family for change in resident's condition or follow up from NP G's assessment. Review of the physician's orders [REDACTED]. Review of the facility's 24-hour Report for [DATE] through [DATE], reflected the following entries related to Resident #1: [DATE] - paper report could not be located. [DATE] - nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. [DATE]- nothing noted from day shift or evening shift- Night shift noted- FSBS, muscle weakness. Interview with ADON A on [DATE] at 2:00 p.m. revealed she had not been able to locate the 24-hour report for [DATE]. Review of Resident #1's Nurse's notes from [DATE] to [DATE] reflected no documentation from any shift addressing Resident #1's status or attempts to obtain ordered labs. Review of Resident #1's Nurse's notes on [DATE] entered by RN C at 10:05 a.m. revealed, Change of condition. Notified MD about sob/increase respirations which started on [DATE]. See SBAR Review of Resident #1's SBAR- Change of Condition completed by RN C on [DATE] at 10:05 a.m. revealed, .The problem .I am calling about .sob/increased respirations .This started on: [DATE] .The problem .has gotten worse since it started .Other things that have occurred with this problem .decrease po intake .Most recent blood pressure: ,[DATE], Pulse 115- New irregular pulse, Respirations 20, most recent temp [AGE].5 most recent O2 sats: [AGE] %.Mental status .decrease level of consciousness .Respiratory evaluation .Shortness of breath, labored or rapid breathing .describe decrease appetite: No oral intake x 2 consecutive meals .decreased urinary output .Reported to: (NP G) on [DATE] at 9:45 a.m. Recommendations of Primary Clinician: Stat cxr (chest X-Ray) , UA with C&S, IV fluids send to ER for eval (evaluation). Date and time of family notification: [DATE] 11:00 a.m. Review of Resident #1's nurse's note on [DATE] entered by RN C at 1:01 p.m. revealed, Res (resident) noted to have low O2 stats this am upon initial rounds res 02 stats were [AGE] on r/a (room air) o2 applied per nasal cannula increased to 95% with 3 L (liters) of 02 call placed to NP to report change in condition new orders received for normal saline at 50 cc/hr x 1 L and stat cxr (chest X-Ray) upon reassessing res O2 stats noted to have dropped to [AGE]% O2 increased to 5 L with mask O2 stats remained the same 911 called for transport to ( hospital name) rp (representative) called and notified of transport and res current condition. Review of the Resident #1's lab results report dated [DATE] reflected, collected date/time [DATE] 3:00 a.m. Resulted date/time: [DATE] 6:39 p.m. Order comments: Critical BUN, Creatinine, and [MED] called to RN S on [DATE] at 6:38 p.m. [MED] 1[AGE] CH (critical high) Ref Range- ,[DATE] .BUN 144 CH Ref Range ,[DATE] .Creatinine 8.1 CH Ref Range 0XXX,[DATE]. 2. Urinalysis report reflected .WBC (white blood cells) 99 ref range-,[DATE] .Bacteria .Moderate . Interview with NP G on [DATE] at 11:30 a.m. revealed BUN and Creatinine levels as high as Resident #1's were indicative of [MEDICAL CONDITION]. She stated Resident #1's elevated [MED] level would be indicative of dehydration. Review of the facility's laboratory request binder revealed the following undated notice in the front of the binder, .Weekend Policy .(Lab Name) provides daily route service Monday through Friday .No routine draws will be collected on the weekends .Scheduling of necessary Saturday draws must be called into the laboratory .Scheduling of necessary Sunday draws must be called into the laboratory .As always (Lab Name) provides around the clock STAT service for critical patients . Review of Resident #1's Hospital Physician consultation report dated [DATE] reflected: .Reason for admission: Septic Shock .I saw the patient in the Emergency Department, at which point, she was noted to be unresponsive with rattling breath sounds audible. Systolic blood pressure was 68, pulse oximetry was 92%.Mucous membranes were dry .Laboratory studies were notable as mention in the HPI for [MED] of 181, potassium of 7.0, BUN and creatinine of 137 and 8.8. [MEDICATION NAME] was 7.3. More than 100 WBC's on UA with a white blood cell count of 20 .It appears, based on her physical exam, review of her hemodynamics, and laboratory studies, that the patient has a high risk of mortality. The patient has an out of hospital Do Not Resuscitate. Hence, palliative care was involved fairly urgently . Review of Resident #1's Hospital Nurse's notes reflected, on [DATE] at 11:11 a.m. Resident #1 arrived by E[CONDITION]. Presenting complaint: E[CONDITION] states patient coming from (facility name). Patient is normally responsive per staff. Staff reports patient not eating or drinking weak for several days. Staff called 911 because patients sat decreased to 70's and patient was unresponsive and appears to be struggling to breath. BP ,[DATE], then ,[DATE] .3:30 p.m. Patient expired. Time of death 2:30 p.m. An interview with RN C on [DATE] at 10:30 p.m. revealed she was Resident #1's charge nurse 6:00 a.m. to 2:00 p.m. on [DATE] and [DATE]. She said on [DATE] Resident #1 had been on a slow decline. She was not as responsive as usual but was still eating some. She stated when NP G came in that day, [DATE], she asked her to assess Resident #1. She stated NP G evaluated the resident and ordered labs and a UA to rule out UTI to be completed by [DATE]. She stated it was around the end of her shift, so she put the orders in the computer system, and placed the lab requisition in the laboratory binder and placed a copy of the order on top of the 24-hour report clip board. She stated she communicated with oncoming staff about the Resident #1's condition but did not remember if she put anything on the 24-hour report. She stated she did not call the family about the resident's decline or the treatments ordered. She stated she worked Monday through Friday, and when she returned on [DATE], LVN E stated the resident's labs were drawn early that morning, but he had not been able to get a UA. She stated after she made rounds around 6:30 a.m. to 7:00 a.m. she noted the resident's O 2 sats were low, so she put her on O2 and they came back up. She stated she finished her rounds and called NP G around 8:,[DATE]:30 a.m. She stated the NP ordered stat chest X-Ray and UA. She stated she obtained the UA and called the laboratory for pick up and ordered the X-Ray. She stated she attempted to feed the resident who was unable to take anything by mouth. LVN E stated she called the NP back around 9:00 a.m. to 9:30 a.m. to tell her about Resident #1's decreased PO intake and received an order for [REDACTED]. She stated she was not aware she had to call the laboratory to have labs drawn on the weekends, since she worked Monday through Friday. She stated she should have documented on a SBAR when she had the NP check on the resident on [DATE], which would have prompted her to call the family, and start a follow up process in the record. Interview with LVN E on [DATE] at 2:04 p.m. revealed he had worked from 10:00 p.m. to 6:00 a.m. on [DATE], [DATE] and [DATE]. He stated he was not aware of any lab requests for Resident #1 until the lab technician came in around 3:00 a.m. on [DATE] to do routine labs. He stated the lab technician had told him there was a request for a UA for Resident #1. He stated he went and attempted to get the UA but was unable to obtain. LVN E stated he told the oncoming nurse that the UA had not been done. He stated he should have documented his attempts in the progress note and placed it on the 24-hour report but failed to do so. He stated Resident #1 slept most of the night and he was unaware of any change in condition. Interview with NP G on [DATE] at 11:25 a.m. revealed the nursing staff had alerted her on [DATE] that Resident #1 was lethargic. She stated the resident would present with a blank gaze when she was getting a UTI, so that was why she had ordered the labs. She stated she had told the nurse to have them drawn by [DATE]. She stated she was not aware routine labs were not drawn on the weekends, otherwise she would have ordered it stat for [DATE]. She stated the facility called her Monday, [DATE], about Resident #1's O2 sats, but stated her vitals were ok. She stated she had not seen the lab results that were done, but when she heard the lab values, she stated it appeared the resident was in [MEDICAL CONDITION], and she would have sent her to the ER immediately. She stated she expected the nurses to use nursing judgement, and not wait to call her before sending a resident to ER if their condition continued to worsen. Interview with LVN D on [DATE] at 12:00 p.m. revealed she was the Charge Nurse responsible for Resident #1 on [DATE] and [DATE] from 6:00 a.m. to 10:00 p.m. She stated she was unaware Resident #1 had an order for [REDACTED]. She stated Resident #1 was alright on [DATE], but on [DATE] the CNAs told her they did not want to get Resident #1 up, because she was not doing very well. She stated she told the aides they had to get Resident #1 up, because the family insisted she be gotten up for all meals. She stated the CNAs got her up and took her to breakfast, but after about 30 minutes they had to lay her back down because she was leaning in her chair. LVN D stated she fed Resident #1 once they got her back to bed. She stated she did not think there was anything unusual about the resident, stating her vital signs were OK. Interview with CNA K on [DATE] at 1:15 p.m. revealed she worked 6:00 a.m. to 2:00 p.m. on [DATE], [DATE] and [DATE]. She stated Resident #1 did not eat or drink anything for her over the weekend and she had notified LVN D. She stated they were concerned about getting Resident #1 up since she was so weak, but the nurse insisted they get her up. She stated once they got her up, the resident could not hold herself up in the wheelchair and they had to hold her to keep from falling forward. She stated the resident could not swallow any fluids. Interview with CNA L on [DATE] at 1:25 p.m. revealed she worked 6:00 a.m. to 2:00 p.m. on [DATE], [DATE], and [DATE]. She stated Resident #1 was not doing very well on Saturday, [DATE], stating she was just not herself and was not very responsive. CNA L stated she was worse on Sunday [DATE]. She stated she had observed CNA K trying to get her to eat, and stated she had to hold the resident up in the wheelchair to keep her from falling out. She stated she stayed with the resident while CNA K went to get the nurse. She stated when LVN D came and saw Resident #1, she stated, she needed to go back to bed. CNA L stated she and LVN D put the resident back to bed. She stated the resident was not short of breath, but she sounded a little raspy. She stated the resident did not always eat well but would always drink fluid. CNA L stated that day the fluids would run right back out of her mouth. She stated had RN C been here over the weekend, she felt like she would have sent her to the hospital. Interview with CNA M on [DATE] at 2:40 p.m. revealed she had worked the 2:00 p.m. to 10:00 p.m. shift on [DATE], [DATE] and [DATE]. She stated she had attempted to feed Resident #1 on Friday, [DATE], and she could not get her to open her eyes or her mouth. She stated she reported to LVN F, who told her she would go and check on her. CNA M stated she did not feed her on Saturday, [DATE], or Sunday, [DATE]. She stated Resident #1 usually would drink for her and eat her sweets, but she had not been able to get her to eat or drink. She stated Resident #1 was not her usual self. Interview with LVN F on [DATE] at 2:55 p.m. revealed she was the Charge Nurse on 2:00 p.m. to 10:00 p.m. shift on [DATE] and had fed Resident #1. She stated she was not aware of any lab request that had been made and did not note any change in her condition on her shift. Interview with Resident #1's MD on [DATE] at 11:48 a.m. revealed he was not made aware of Resident #1's worsening condition until [DATE]. He stated he had not been informed about the laboratory results, or the delay in obtaining the lab results. Once informed what the lab results were, he stated Resident #1 would have been immediately hospitalized . He stated he was unaware routine labs were not being drawn over the weekend and he thought they had already addressed the issue in the past. He stated he thought that was why the facility had changed lab services. He stated his expectation when he ordered labs, was for them to be done within ,[DATE] hours unless he ordered them stat, then they would need to be done sooner. Interview with the DON on [DATE] at 11:00 a.m. revealed the facility's lab procedure for routine labs were Monday through Friday, unless the staff called the lab to let them know of a request for the weekend. She stated stat orders must always be called in. She stated the staff was supposed to place the requisition in the lab binder once the lab was called and the order was written and then placed on the 24-hour report for follow up. She stated the staff was also expected to do a SBAR on any change of condition, which triggered them to call the MD, family and required follow up. Interview with Resident #1's family member on [DATE] at 05:23 p.m. revealed she went to the facility to speak with the DON about the fact they received a call right before the resident was sent to the hospital and had not been informed from the facility about the condition the resident was in. She stated she told the DON only one family member was able to make it to the hospital in time to say goodbye, before the resident passed away. She stated the DON apologized and made excuses. She stated she had not received any follow up call from the facility related to her complaint. An interview with the DON on [DATE] at 10:10 a.m. revealed Resident #1's family came to the facility on [DATE] upset the facility had not notified them earlier or indicated how bad the resident was. She also had stated the family member had said resident had a UTI and the resident was supposed to be getting routine UA with C&S and wanted to know why she had not been receiving that. The DON stated she informed the family member that routine UA's were not customary, and it required a physician order [REDACTED]. The DON stated she did not review the resident's record, nor did she interview any of the staff. She stated not long after the family came in, she had another issue come up and did not go back and review Resident #1's record. In a follow up interview with the DON on [DATE] at 9:00 a.m. she stated she had learned a valuable lesson from this incident, and stated had she investigated the grievance, reviewed the resident's record and talked with the staff, she would have been aware of the communication breakdown and the staff's failure to address the resident's change in condition. She stated moving forward that would be the expectation. She stated when she did disciplinary action on RN C she readily admitted her failings and was aware going forward of the expectations. She stated when she did disciplinary action on LVN D, she continued to insist she did not see a change in condition for Resident #1. Based on this, the decision to terminate LNV D was made. The DON stated she also received a disciplinary warning for her failure to investigate the grievance. Review of a Disciplinary Action Form, dated [DATE], reflected LVN D was terminated due to failure to follow policy and procedure for change of condition. Review of a Disciplinary Action Form, dated [DATE], reflected the DON received a written warning for failure to follow policy and procedure grievances. Review of a Disciplinary Action Form, dated [DATE], reflected RN C received a written warning for failure to follow policy and procedure for change of condition and laboratory procedures. Review of the facility's policy, Request for Diagnostic Services, dated [DATE], reflected, .All requests for diagnostic services must be ordered by the resident's Attending Physician .Orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED]. Review of the facility's policy, Change in a Resident's Condition or Status, dated [DATE], reflected Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and /or status .The Nurse Supervisor/Charge Nurse will notify the resident's Attending physician .when there has been.A significant change in resident's physical/emotional/mental condition. The Nurse Supervisor/Charge Nurse will notify the resident's family or representative .when there has been.A significant change in resident's physical/emotional/mental condition.The nurse supervisor/charge nurse will be record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . An IJ was identified on [DATE]. The Administrator and DON were notified of the IJ on [DATE] at 3:08 p.m. and a plan of removal to remove the immediacy was requested at that time. Interview with the Administrator on [DATE] at 3:07 p.m. revealed she believed the IJ occurred due to lack of communication which started with RN C's failure to follow the procedure for requesting labs. The Administrator said to prevent further occurrences the entire nursing department had been educated on change of condition, assessments, and documentation, laboratory procedures and Nurse Management rounding procedures seven days a week. She stated the facility would be having a QAPI Committee meeting with the Medical Director to review interventions, to identify root causes and to provide direction of identified areas of concern. Review of the facility's Plan of Removal, dated [DATE], reflected the following: Immediate Action Steps Facility implemented the following Action Plan that affected Resident #1 and has the potential to affect other residents . 2. Employee RN C received disciplinary action for failure to follow lab policy and procedure. 3. Employee LVN D received disciplinary action for failure to notify patient change of condition and was terminated. 4. DON received disciplinary action and in-service on grievance policy. 5. DON and the ADON A and ADON B were in-serviced by the Administrator on rounding on patients on change of condition log and monitoring the 24-hour report and SBAR 6. The Administrator and DON were in-serviced on Abuse and Neglect by the RDO. 7. DON/ADON audited lab orders for discrepancies. No discrepancies noted. 8. Rounds completed on residents, chart reviews completed. Audited all labs facility wide. No discrepancies. 9. Medical directors notified Completion date of these actions was [DATE] In Service Education The following in services were provided to staff on ,[DATE] and [DATE] 1. Nursing staff, physicians and physician extenders on Lab policy and Procedures 2. Nursing staff on Change of Condition and protocol 3. Nursing staff on SBAR 4. All staff abuse and neglect Nursing staff will not be allowed to work their shifts until they complete the assigned in-services. Monitoring Administrator/DON have implemented the following systems of monitoring; 1. ADONS will audit lab orders each day and compare to the service log. The charge nurse is responsible for completing the service log: see attached service log which includes patient name, ordered test, collection time, draw site, comments, result received, physician notified. It also includes lab rep and nurse signature lines. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 2. Nursing staff to notify DON/ADON on all changes of condition during business hours and document on change of condition log. After hours the charge nurse will notify the DON/ADON on call via on call phone and document on change of condition log. 3. DON/ADON will complete morning start up reviewing the 24-hour report daily to insure the following are documented appropriately and accurately completed: a. change of condition log b. lab service log c. x-ray orders d. new orders e. SBAR They will round on patients with changes of condition, review their charts and 24-hour report. The facility has a DON and ADON Mon- Friday and an ADON on the weekends to have 7 day a week DON/ADON coverage. 4. These systems were implemented [DATE]. Monitoring of the plan of removal included: Review of a facility in-services, dated [DATE] through [DATE], reflected nursing department staff were trained regarding the following topics: Changes of condition - who to report to, things to mention, who to notify, how to document. Lab Ordering process and Lab follow up On [DATE] individual staff interviews were conducted with RN C, LVN I, RN J, RN N, ADON B, LVN F, and LVN O from 1:40 p.m. to 3:00 p.m. On [DATE] individual staff interviews were conducted with RN P, RN Q, LVN R and ADON A from 9:20 a.m. to 9:55 a.m. Staff represented all three shifts including double weekends and PRN staff. Staff were asked to describe the training they had received. All employees interviewed were able to correctly answer questions and described all changes of conditions that would be reported to the Supervisor, MD and family. Charge nurses said they would assess the change of condition, document actions, notify residents' physician, family, and DON, obtain/transcribe orders as indicated, follow course of treatment, and monitor until resolved or notify physician, family and DON if condition worsens or does not resolve. All staff were aware of the laboratory procedure. On [DATE] from 8:30 a.m. to 10:15 a.m. four individual residents (Resident #2, #3, #4 and #5) were reviewed for recent changes of condition. All residents reviewed had an SBAR completed with description of the change of condition, notification of the MD with follow up orders and lab request, assessment of the resident and notification of family. On [DATE] at 10:30 a.m. the Administrator was informed the IJ was removed. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to implement written policies for abuse by not employing or engaging individuals who have been found guilty of abuse by a court of law for one (Employee E) out of ten sampled employees reviewed for criminal history checks. The facility/management company hired/engaged Employee E who was convicted of a sexual offense against a minor, which was a lifetime bar to employment and had access to residents. An Immediate Jeopardy (IJ) was identified on 12/13/16. While the IJ was removed on 12/14/16, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of widespread due to they were still monitoring the effectiveness of the plan of removal. This failure could affect the 80 residents, who reside at the facility, by placing them at risk for abuse or mistreatment. Findings include: Review of the policy Abuse Prevention Program (dated August 2006) on 12/13/16 at 11:56 P.M. revealed 2. Our facility conducts employee background checks and will not knowingly employ any individual who had been convicted of abusing, neglecting or mistreating individuals. Review of the policy Background Screening Investigations (dated November 2015) on 12/13/16 at 1:25 P.M. revealed 4 .information indicating that the individual has been convicted of abuse, neglect or mistreatment of [REDACTED]. Review of the policy Background Check dated March 2014 revealed the bars to employment according to the Texas Health and Safety Code Chapter 250, which included Texas Penal Code 21.11, Indecency with a Child. Review of the employee lists on 12/13/16 at 10:50 A.M. revealed Employee E was employed at the corporate level with the hire date of 04/05/10. Interview on 12/13/16 at 9:40 A.M. with the Administrator revealed Employee E came into the facility. The Administrator stated Employee E worked with the managing corporation for the facility. Interview on 12/13/16 at 1:35 P.M. with Employee E revealed he worked at the corporate level and that his office was recently relocated in a sister facility. Employee E stated he went to the server room and nurses stations when he came to the facility. Employee E stated the last time he was at the facility was around Thanksgiving. Employee E stated he helped out at the Thanksgiving party by serving drinks and food to the residents or helping guests sit down. Interview with the Administrator on 12/13/16 at 2:05 P.M. revealed Employee E was in the building one day last week during the day. Employee E was replacing a computer on a nurses medication cart in the 700 hall. Interview on 12/13/16 at 11:40 A.M. with Human Resources B revealed human resources conducted criminal background checks prior to hire. Human Resources B stated there was a list of bars to employment, such as child abuse/molestation, fraud, assault with a deadly weapon or sexual assault. Interview with the Administrator on 12/13/16 at 10:38 A.M. confirmed that background checks were performed prior to hire. Interview with the Administrator on 12/13/16 at 10:10 A.M. revealed he was the abuse coordinator. He stated if a candidate came up with a criminal background that he and Human Resources look at criteria to determine if the issue would disqualify the candidate from employment. The Administrator stated the facility would not hire a candidate with history of drugs, aggravated assault of a violent nature, history of sexual assault or childhood neglect. The Administrator said that he was sure that Employee E went to the clinical areas. Interview on 12/13/16 at 11:52 A.M. with Human Resources B revealed the facility's abuse policy included the lifetime bars to employment listed in the Texas Health and Safety Code 250.006 Interview on 12/13/16 at 2:02 P.M. with Human Resources B revealed the Texas Department of Public Safety report was not in Employee E's file. Human Resources B stated she started with the corporation in January 2016 and did not know if the initial background check( for Employee E) at time of hire was performed . Human Resources B stated she ran the report on 12/13/16 since it was not in Employee E's file She stated she did not know about the bar to employment until today. Human Resources B stated the annual Employee Misconduct registry checks did not show anything. Review of the Texas Department of Public Safety background check (dated 12/13/16) revealed Employee E had a conviction of a sexual offense against a minor (disposition date 06/01/1998, which was lifetime bar to employment according to the Texas Health and Safety Code Chapter 250. Interview with Human Resources B at 5:50 P.M. revealed she was hired on 01/04/16. She stated Employee E started employment before she started her employment with the corporation. She did not know if a criminal background check was performed on Employee E at the time of hire. An IJ was identified on 12/13/16 . The Administrator was notified of the IJ on 12/13/16 at 2:15 P.M. and a plan of removal was requested. Interview with the Administrator on 12/13/16 at 5:05 P.M. revealed he did not know who or what was the actual bar to employment. The employee was unhireable and I'm assuming that's where the IJ occurred. If it's corporate, I'm concerned because it put my facility in IJ. I feel like I had no control just because I don't know who was the employee or the actual offense. Review of the plan of removal , accepted on 12/14/16 at 7:45 A.M. the Chief Operating Officer verified the offense with Employee E and instructed Employee E not to visit the facility until further notice. Employee E was terminated as of 4:00 P.M. on December 13, 2016 and instructed not to visit the facility in the future. The Administrator and Human Resources B reviewed current background check policies. There was a change in the background check policy, implemented 12/13/16, for annual criminal checks to be conducted on current employees. On December 14, 2016 Human Resources A and B ran a criminal check on all current employee at the facility and corporate level. The Chief Operating Officer conducted inservice training on how to properly run the background checks, specifically the online portals for criminal history checks, BARS (sic) of employment, NAR/EMR( employee misconduct registry) Federal and State Exclusive list and any other required background check. Should Human Resources A or B have questions or concerns regarding the results of any of these checks, they will bring the results to the Chief Operating Officer for discussion and review. The Administrator and Human Resources will add criminal background reviewed and verification process to monthly Quality Assurance process for the next 4 months and will monitor it quarterly thereafter. Review of 105 criminal background checks for corporate and facility employees from the Department of Public Safety on 12/14/16 at 12:25 P.M. revealed no automatic bars to employment as per Section 250 of the Texas Health and Safety Code. Interview with Human Resources B on 12/14/16 at 12:10 P.M. revealed she was re-inserviced about background checks. She stated the Chief Operating Officer talked about performing annual background checks and upon time of hire. She stated there was a review of the list of bars to employment and if there was a conviction on the background check to discuss it with the Chief Operating Officer. Interview with Human Resources D on 12/14/16 at 12:20 p.m. revealed she was re-trained on conducting criminal backgrounds and EMR/NAR at time of hire and an an annual basis. She stated the retraining included the list of bars to employment. She was instructed to call the Chief Operating Officer for any questions about background checks. The form 672, Resident Census and Conditions of Residents, dated 12/13/16, reflected a census of 80 residents.

Based on observation, interview and record review, the facility failed to not employ or engage individuals, who have been found guilty of abuse by a court of law for one (Employee E) out of ten sampled employees reviewed for criminal history checks. The facility/management company hired/engaged Employee E who was convicted of a sexual offense against a minor, which was a lifetime bar to employment and had access to residents. An Immediate Jeopardy (IJ) was identified on 12/13/16. While the IJ was removed on 12/14/16, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of widespread due to they were still monitoring the effectiveness of the plan of removal. This failure could affect the 80 residents, who reside at the facility, by placing them at risk for abuse or mistreatment. Findings include: Review of the employee lists on 12/13/16 at 10:50 A.M. revealed Employee E was employed at the corporate level with the hire date of 04/05/10. Interview on 12/13/16 at 9:40 A.M. with the Administrator revealed Employee E came into the facility. The Administrator stated Employee E worked with the managing corporation for the facility. Interview on 12/13/16 at 1:35 P.M. with Employee E revealed he worked at the corporate level and that his office was recently relocated in a sister facility. Employee E stated he went to the server room and nurses stations when he came to the facility. Employee E stated the last time he was at the facility was around Thanksgiving. Employee E stated he helped out at the Thanksgiving party by serving drinks and food to the residents or helping guests sit down. Interview with the Administrator on 12/13/16 at 2:05 P.M. revealed Employee E was in the building one day last week during the day. Employee E was replacing a computer on a nurses medication cart in the 700 hall. Interview on 12/13/16 at 11:40 A.M. with Human Resources B revealed human resources conducted criminal background checks prior to hire. Human Resources B stated there was a list of bars to employment, such as child abuse/molestation, fraud, assault with a deadly weapon or sexual assault. Interview with the Administrator on 12/13/16 at 10:38 A.M. confirmed that background checks were performed prior to hire. Interview with the Administrator on 12/13/16 at 10:10 A.M. revealed he was the abuse coordinator. He stated if a candidate came up with a criminal background that he and Human Resources look at criteria to determine if the issue would disqualify the candidate from employment. The Administrator stated the facility would not hire a candidate with history of drugs, aggravated assault of a violent nature, history of sexual assault or childhood neglect. The Administrator said that he was sure that Employee E went to the clinical areas. Interview on 12/13/16 at 11:52 A.M. with Human Resources B revealed the facility's abuse policy included the lifetime bars to employment listed in the Texas Health and Safety Code 250.006 Interview on 12/13/16 at 2:02 P.M. with Human Resources B revealed the Texas Department of Public Safety report was not in Employee E's file. Human Resources B stated she started with the corporation in January 2016 and did not know if the initial background check( for Employee E) at time of hire was performed . Human Resources B stated she ran the report on 12/13/16 since it was not in Employee E's file. Review of the Texas Department of Public Safety background check (dated 12/13/16) revealed Employee E had a conviction of a sexual offense against a minor (disposition date 06/01/1998, which was lifetime bar to employment according to the Texas Health and Safety Code Chapter 250. Interview with Human Resources B at 5:50 P.M. revealed she was hired on 01/04/16. She stated Employee E started employment before she started her employment with the corporation. She did not know if a criminal background check was performed on Employee E at the time of hire Review of the policy Abuse Prevention Program (dated August 2006) on 12/13/16 at 11:56 P.M. revealed 2. Our facility conducts employee background checks and will not knowingly employ any individual who had been convicted of abusing, neglecting or mistreating individuals. Review of the policy Background Screening Investigations (dated November 2015) on 12/13/16 at 1:25 P.M. revealed 4 .information indicating that the individual has been convicted of abuse, neglect or mistreatment of [REDACTED]. Review of the policy Background Check dated March 2014 revealed the bars to employment according to the Texas Health and Safety Code Chapter 250, which included Texas Penal Code 21.11, Indecency with a Child. An IJ was identified on 12/13/16 . The Administrator was notified of the IJ on 12/13/16 at 2:15 P.M. and a plan of removal was requested. Interview with the Administrator on 12/13/16 at 5:05 P.M. revealed he did not know who or what was the actual bar to employment. The employee was unhireable and I'm assuming that's where the IJ occurred. If it's corporate, I'm concerned because it put my facility in IJ. I feel like I had no control just because I don't know who was the employee or the actual offense. Review of the plan of removal , accepted on 12/14/16 at 7:45 A.M. the Chief Operating Officer verified the offense with Employee E and instructed Employee E not to visit the facility until further notice. Employee E was terminated as of 4:00 P.M. on December 13, 2016 and instructed not to visit the facility in the future. The Administrator and Human Resources B reviewed current background check policies. There was a change in the background check policy, implemented 12/13/16, for annual criminal checks to be conducted on current employees. On December 14, 2016 Human Resources A and B ran a criminal check on all current employee at the facility and corporate level. The Chief Operating Officer conducted inservice training on how to properly run the background checks, specifically the online portals for criminal history checks, BARS (sic) of employment, NAR/EMR( employee misconduct registry) Federal and State Exclusive list and any other required background check. Should Human Resources A or B have questions or concerns regarding the results of any of these checks, they will bring the results to the Chief Operating Officer for discussion and review. The Administrator and Human Resources will add criminal background reviewed and verification process to monthly Quality Assurance process for the next 4 months and will monitor it quarterly thereafter. Review of 105 criminal background checks for corporate and facility employees from the Department of Public Safety on 12/14/16 at 12:25 P.M. revealed no automatic bars to employment as per Section 250 of the Texas Health and Safety Code. Interview with Human Resources B on 12/14/16 at 12:10 P.M. revealed she was re-inserviced about background checks. She stated the Chief Operating Officer talked about performing annual background checks and upon time of hire. She stated there was a review of the list of bars to employment and if there was a conviction on the background check to discuss it with the Chief Operating Officer. Interview with Human Resources D on 12/14/16 at 12:20 p.m. revealed she was re-trained on conducting criminal backgrounds and EMR/NAR at time of hire and an an annual basis. She stated the retraining included the list of bars to employment. She was instructed to call the Chief Operating Officer for any questions about background checks. The form 672, Resident Census and Conditions of Residents, dated 12/13/16, reflected a census of 80 residents.