Every finding on record at Broadmoor Medical Lodge

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 disease and infections for 1 of 4 residents (Resident #1) reviewed for infection control.The facility failed to ensure CNA A and the ADON performed hand hygiene in between glove changes while providing peri care for Resident #1.The facility failed to ensure CNA and the ADON placed Resident #1's catheter bag below bladder level while providing peri care.These failures could place residents at risk for infections.Findings included:Record review of Resident #1's face sheet, dated 4/22/2026, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of stroke, type 2 diabetes, bladder dysfunction, and stage 4 pressure ulcer of sacrum.Record review of the resident's care plan, dated 7/17/2024, revealed the following was care planned for the resident: The resident has a Foley Catheter and is at risk for UTI R/T Stage 4 to her sacrum with one of the listed interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door. The care plan also stated that the resident was At increased risk of multidrug-resistant organism acquisition related to present of a wound.In an observation on 4/22/2026 at 9:45 AM, CNA A and the ADON were providing peri care for Resident #1. PPE was donned on both staff. Both staff performed hand hygiene prior to entering the resident's room. The resident had a bowel movement. Both CNA A and the ADON failed to perform hand hygiene in between three glove changes after touching the resident's fecal matter and body fluid. Observation also revealed that the resident's urinary catheter bag was sitting on the resident's bed at the same level as the urinary bladder. The urinary catheter was covered with a privacy bag. Both staff washed hands after the procedure.In an interview with CNA A on 4/22/2026 at 10:00 AM, she stated she should have hand sanitize in between glove changes. She said she did not have the hand sanitizer with her and did not think of getting it. She stated the risk to the residents included infection. She stated last in-service on infection control was about 2 weeks ago.In an interview with the ADON on 4/22/2026 at 10:15 AM, she stated, she realized she had not performed hand hygiene towards the end when she was putting barrier cream on the resident's buttock. She stated she should have used hand sanitize in between gloves changes. She stated the risk to the resident was infection. She also stated the catheter bag should always be below bladder level. She stated she noticed the bag was on the bed and should not have been placed on the bed. She stated to prevent the tube to be pulled, she should have moved the bag to the other side of the bed while repositioning the resident. She stated the risk of the catheter bag not staying below bladder level included infection. She stated it was her mistake, she stated she also just provided her staff an in-service on infection control 2 weeks ago.In an interview with the DON on 4/22/2026 at 10:22 AM, she stated her expectation of her staff was to perform hand hygiene between glove changes to prevent infection. She stated catheter bags should always be kept below bladder level to prevent the urine to backflow which could cause infection. Record review of the facility's Hand Hygiene policy, dated in 2001, revealed the policy stated Use an alcohol-based handrub. or soap and water for the following situations:.After contact with blood or bodily fluid,. after removing gloves.Record review of the facility's Catheter Care policy, revised January 3, 2023, revealed the policy stated the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #1) reviewed for catheter care.The facility failed to ensure CNA A and the ADON place the catheter bag below bladder level while providing incontinent care. This failure could result in infection.Findings included:Record review of Resident #1's face sheet, dated 4/22/2026, revealed the resident was a [AGE] year-old female admitted on [DATE] with diagnoses of stroke, type 2 diabetes, bladder dysfunction, and stage 4 pressure ulcer of sacrum.Record review of the resident's care plan, dated 7/17/2024, revealed the following was care planned for the resident: The resident has a Foley Catheter and is at risk for UTI R/T Stage 4 to her sacrum with one of the listed interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door. The care plan also stated that the resident was At increased risk of multidrug-resistant organism acquisition related to present of a wound.In an observation on 4/22/2026 at 9:45 AM, CNA A and the ADON were providing peri care for Resident #1. PPE was donned on both staff. Both staff performed hand hygiene prior to entering the resident's room. The resident had a bowel movement. Both CNA A and the ADON failed to perform hand hygiene in between three glove changes after touching the resident's fecal matter and body fluid. Observation also revealed that the resident's urinary catheter bag was sitting on the resident's bed at the same level as the urinary bladder. The urinary catheter was covered with a privacy bag. Both staff washed hands after the procedure.In an interview with the ADON on 4/22/2026 at 10:15 AM, she stated, she realized she had not performed hand hygiene towards the end when she was putting barrier cream on the resident's buttock. She stated she should have used hand sanitize in between gloves changes. She stated the risk to the resident was infection. She also stated the catheter bag should always be below bladder level. She stated she noticed the bag was on the bed and should not have been placed on the bed. She stated to prevent the tube to be pulled, she should have moved the bag to the other side of the bed while repositioning the resident. She stated the risk of the catheter bag not staying below bladder level included infection. She stated it was her mistake, she stated she also just provided her staff an in-service on infection control 2 weeks ago.In an interview with the DON on 4/22/2026 at 10:22 AM, she stated her expectation of her staff was to perform hand hygiene between glove changes to prevent infection. She stated catheter bags should always be kept below bladder level to prevent the urine to backflow which could cause infection. Record review of the facility's Catheter Care policy, revised January 3, 2023, revealed the policy stated the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for eight of eighteen residents (Residents #39, #73, #84, #98, #109, #125, #126, and #127) reviewed for privacy and confidentiality. The facility failed to ensure LVN E secured Residents #39, #73, #84, #98, #109, #125, #126, and #127's medical information before leaving her cart on 03/03/2026. This failure could place the residents at risk of their medical information being accessed by unauthorized individuals. Findings included: Record review of Resident #39's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #73's Face Sheet, dated 03/05/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #84's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #98's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with localized swelling (enlargement of a part of a body due to accumulation of fluid). Record review of Resident #109's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #125's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #126's Face Sheet, dated 03/05/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #127's Face Sheet, dated 03/05/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension. During an observation on 03/03/2026 at 9:41 AM revealed an untitled piece of paper was left on top of a nurse's cart parked in the hallway. On the piece of paper were the names of Residents #39, #73, #84, #98, #109, #125, #126, and #127. Written beside each of the names of the residents were the resident's blood pressures, pulse rates, temperatures, and oxygen saturations. The nurse's cart was unattended and was facing the hallway with several staff and residents passing by the cart. During an observation and interview on 03/03/2026 at 9:42 AM revealed LVN E flipped the piece of paper as soon as she came back to her cart. She said she was looking for a resident; that was why she left her cart. She said the piece of paper had the residents' vital signs and was confidential. She said she should have secured the paper before leaving the cart. She said vital signs were medical information and when exposed to unauthorized individuals could be a HIPAA (law protecting health information aimed at ensuring confidentiality) violation. During an interview on 03/05/2026 at 6:45 AM, ADON A said the staff should have turned over the paper with the residents' vital signs before leaving the cart. She said vital signs were confidential medical information and could be a HIPAA violation if other individuals, that had nothing to do with the residents' care, would be able to see them. She said the expectation was, before leaving the cart, the staff should have secured it somewhere so unauthorized individuals would not see them. She said the staff could have flipped it, put it under the laptop, or locked it in one of the drawers. She said she would coordinate with the DON to do an in-service about confidentiality of medical records. During an interview on 03/05/2026 at 7:11 AM, the Administrator said the expectation was for the staff to have turned the paper upside down before leaving the cart because what was written on the paper was supposed to be confidential. He said confidential information could not be disclosed to unauthorized individuals. He said he would coordinate with the DON regarding confidentiality of medical records. During an interview on 03/05/2026 at 7:39 AM, the DON said if what was written on the piece of paper were the vital signs of the residents, then the paper should not be left exposed because unauthorized individuals might see it. She said medical information about a resident should be protected and not be visible to everybody to see. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said if the confidential information was exposed, non-nursing staff, other residents, and visitors would be able to see it. She said the expectation was for the staff to practice confidentiality of medical records. She said the staff should have flipped the paper, locked it inside the cart, or brought it with her. The DON stated she would start an in-service about confidentiality of medical records and would closely monitor the staff on their adherence to the policy. Record review of the facility's policy, Protected Health Information (PHI), Management and Protection of 2001 MED-PASS, Inc. revised April 2014 reflected Policy Statement: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws . Policy Interpretation and Implementation . 1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

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 three of eighteen residents (Residents #85, #89, And #128) and one LVN (LVN E) of three LVNs reviewed for medication storage. 1. The facility failed to ensure that Resident #85 did not have an eye drop inside the room on 03/03/2026. 2. The facility failed to ensure that Resident #89 did not have eye drops inside the room on 03/03/2026. 3. The facility failed to ensure that a skin barrier was not left on top of Resident #128's overbed table on 03/03/2026. 4. The facility failed to ensure LVN E did not leave a plastic vial of medication for breathing treatment on top of the nurse's cart unattended on 03/03/2026. 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 #85's Face Sheet, dated 03/05/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with age-related macular degeneration (irreversible vision loss) and legal blindness (vision impairment that affects central or peripheral visions, or both). Record review of Resident #85's Comprehensive MDS Assessment, dated 02/27/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident had age-related macular degeneration and legal blindness. Record review of Resident #85's Comprehensive Care Plan, dated 01/26/2026, reflected that the resident had legal blindness and macular degeneration, and the intervention for both was to administer eye medication as ordered. Record review of Resident #85's Physician's Order, dated 01/09/2025, reflected Polyvinyl Alcohol Ophthalmic Solution 1.4 % (Polyvinyl Alcohol) Instill 1 dose in both eyes every 24 hours as needed for teary eyes. Record review on 03/03/2026 of Resident #85'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 on 03/03/2026 at 9:25 AM revealed Resident #85 was not inside her room. It was observed that there was a container of eyedrops on top of the resident's overbed table. During an observation and interview on 03/03/2026 at 9:38 AM, RN B said she did not notice Resident #85 has an eye drop inside her room. She said the MA was already administering her eyedrops, so she was not sure why there was an eyedrop inside the resident's room. She took the eye drop and said she would talk to the resident to see who brought the eye drop. She said medications should not be inside the room of the resident because the resident might use it more than recommended. She said confused residents might consume them as well that could result in upset stomach and nausea. 2. Record review of Resident #89's Face Sheet, dated 03/03/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a lack of coordination and anxiety. Record review of Resident #89's Comprehensive MDS Assessment, dated 02/16/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a lack of coordination and anxiety. Record review of Resident #89's Comprehensive Care Plan, dated 02/12/2026, reflected that the resident had ADL self-care performance deficit and used anti-anxiety medications. The interventions were to assist with ADLs and observe memory loss, confusion, and blurred vision. Record review on 03/03/2026 of Resident #89's Physician Order reflected that the resident did not have an order for eyedrops. Record review on 03/03/2026 of Resident #89'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 on 03/03/2026 at 9:13 AM revealed Resident #89 was not inside her room. It was observed that three eye drops were on top of the resident's overbed table. 3. Record review of Resident #128's Face Sheet, dated 03/03/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity, muscle wasting (loss of muscle leading to its shrinking and weakening), and contact dermatitis (inflammation of the skin). Record review of Resident #128's Comprehensive MDS Assessment, dated 02/20/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment reflected the resident was always incontinent for bowels and bladder. Record review of Resident #128's Comprehensive Care Plan, dated 02/04/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to assist with personal hygiene. Record review of Resident #128's Physician Orders, dated 01/30/2026, reflected May apply house barrier cream Q shift as preventative every shift for prevention. Record review on 03/03/2026 of Resident #128'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 03/03/2026 at 9:09 AM revealed Resident #128 was in her bed, awake. It was observed that there were two tubes of barrier creams on top of the resident's side table. The resident said the staff would use the creams after the staff changed her brief. During an observation and interview on 03/03/2026 at 9:45 AM, LVN D said the barrier creams should not be on top of Resident #128's side table because the resident might mistakenly use it as a toothpaste or use it as a moisturizer. She said there would be confused residents in the facility that might consume the barrier cream. She took the tube of barrier cream and said the tubes should be locked in a cart, and the staff would just ask them if they were going to use the skin barrier. She said she did not notice Resident #89 had eye drops inside her room. She went inside Resident #89's room and saw the eye drops on top of Resident #89's overbed table. She said eye drops should not be inside the resident's room because if the resident was using it, it was not being monitored. She said she would also check if the resident had an order for eye drops so she could request an order if Resident #89 needed the eye drop. She took the eye drops and said she would talk to the resident when she came back to the facility. 4. During an observation on 03/03/2026 at 9:41 AM revealed a vial of medication for breathing treatment was observed on top of a cart unattended. During an observation and interview on 03/03/2026 at 9:42 AM, LVN E said no medications should be left on top of the cart unattended because residents might be able to reach for it and consume it. She said she was looking for a resident; that was why she left her cart but should have placed the medication inside the drawer before leaving her cart. she took the medication for breathing treatment and put it inside her cart. During an interview on 03/05/2026 at 6:45 AM, ADON A said no medications should be inside the residents' room because the residents might be using them with any assessment and orders. She said it could result in adverse reactions. She said the staff could have been administering the eyedrops, and then the resident would self-administer also. She said if those were pills, it could result in overdose. She said barrier creams should not be within the reach of the residents because the creams had chemicals in them that could cause irritation and stomach upset. She said the staff should have secured the medication for the breathing treatment before leaving the cart because residents passing the cart could get it and consume it. She said she would coordinate with the DON to do an in-service about medication storage. She said she would educate the family members to give the staff any medication that they would be bringing. During an interview on 03/05/2026 at 7:11 AM, the Administrator said the expectation was for the staff to make sure there was no medications inside the resident's rooms or on top of the carts unattended because the residents might consume the medications or use them inappropriately. He said he was not a clinician and would let the DON take a lead on the issue. During an interview on 03/05/2026 at 7:39 AM, the DON said medications should not be stored inside the resident's room because the residents might use them inappropriately that could result in adverse reactions. She said skin barriers were applied topically and could be harmful when ingested. She said the same rationale applied to the eye drops found inside the rooms of the residents and the medication left on top of the nurse's cart. She said the expectation was for the staff to be vigilant that when they entered the residents' room to check for any medications, for staff using the skin barriers to not leave the tubes within reach of the residents, and not to leave any medications on top of the carts unattended. She said she had already started an in-service about medication storage. Record review of the facility's policy, Storage of Medications 200 I MED-PASS. Inc. revised April 2019 MED-PASS revised 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 . The nursing staff is responsible for maintaining medication storage.

Number of residents sampled: Number of residents cited: 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 1 of 1 kitchen reviewed for food storage, labeling, and dating. The facility failed to ensure all food items in the facility kitchen were dated and discarded prior to their use-by date . These failures could place residents at risk for food contamination and food-borne illness. Finding included: During observation on 03/03/2026 between 9:15 AM and 9:50 AM in the facility's kitchen revealed: 1 Gallon size bag of Frosted Flakes no use by date 1 box of long grain enriched Parboiled rice not properly sealed and exposed to air contaminants. 1 Bag of oats cereal dated with no visible expiration date was observed. 1 Bag of raisin bran dated with no visible expiration date observed. 1 bag of cane sugar date with no visible expiration date observed. 1 bag of opened biscuit mix not properly sealed and exposed to air contaminants. 1 5 lb. bag of graham cracker crumbs opened not properly sealed and exposed to air contaminants. During an interview on 03/05/2026 at 12:05 PM DC, stated he was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. DC confirmed the surveyor observations and stated the listed items would be corrected. DC stated once items are opened they should be properly sealed and dated and that these were oversights. DC stated he was responsible for ensuring policy was followed. All kitchen staff are responsible for labeling and making sure that the items are labeled properly. He said the risk to residents if policy was not followed was a health risk to the residents. The DC stated the bags should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DC stated he will conduct a full in-service of food rotation and storage pertaining to what the proper procedures are dealing with food rotation and storage. DC stated if food items were not dated when opened then they will not be able to know how long they will last. The risk of serving foods that are past use by date or serving food that was not labeled or dated can cause food borne illness. During an interview on 03/05/2026 at 12:45 PM, ADM stated he oversaw all departments, and ensured residents were taken care of. ADM stated he was made aware of the concerns observed in the kitchen and has spoken with the DC. He stated that the issues could cause food contamination and this matter would be resolved. If items are expired they do not want to serve them to residents. The ADM stated the risk of all these concerns observed in the kitchen could result in residents getting sick. The ADM said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. He said the risk to residents if policy were not followed was that they could get sick from food borne illnesses. The ADM stated he would expect the DC to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. The ADM stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. The ADM stated the risk of these concerns not being addressed could result in food contamination and residents becoming ill. ADM stated if foods were not discarded properly, sanitized properly, or heated properly, there was the potential for foodborne illness. Record review of the facility's Food Receiving and Storage Policy, dated July 2014, indicated 6 Dry food that are stored in bins will be removed from original packaging, labeled, and dated ( use by date). Such food will be rotated using a first in - first out system. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: e. Other opened containers must be dated and sealed or covered during storage. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

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 eighteen residents (Resident #10, #18 and #93) and for six of eight direct care staff (RN B, RN C, CNA G, CNA H, CNA J, and COTA I) reviewed for infection control. 1. The facility failed to ensure RN B did not put the two cups of barrier cream she already placed on Resident #10's overbed table, inside the first drawer of her cart on 03/04/2026. 2. The facility failed to ensure CNA H did not put gloves inside her pockets and use them during Resident #18's incontinent care on 03/04/2026. 3. The facility failed to ensure CNA G wore a gown when shaving Resident #93 on 03/03/2026. 4. The facility failed to ensure CNA G and COTA I wore gowns when changing Resident #93's clothes on 03/03/2026. 5. The facility failed to ensure RN C did hand hygiene while passing plates on 03/03/2026.6. The facility failed to ensure CNA J conducted hand hygiene in between assisting feeding two residents on 03/03/2026. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #10's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #10's Comprehensive MDS Assessment, dated 01/22/2026, reflected that the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bowels. Record review of Resident #10's Comprehensive Care Plan, dated 01/31/2026, reflected that the resident had bowel incontinent and one of the interventions was to clean the perineal (area between the thighs) area. During an observation on 03/04/2026 at 6:46 AM revealed RN B put some barrier creams in two cups. After placing creams in the cups, she went inside Resident #10's room and placed the two cups on top of the resident's overbed table. The resident told RN B that she wanted the cream later. RN B took the cups of cream from the overbed table, went back to her cart, opened the first drawer, and placed the two cups inside the drawer. During an interview on 03/04/2026 at 6:54 AM, RN B said since the cups of creams had contact with Resident #10's overbed table, she should have not returned them inside the cart's drawer because the cups could have been contaminated and the contamination could be transferred to the carts and indirectly to other residents. 2. Record review of Resident #18's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #18's Comprehensive MDS Assessment, dated 12/18/2025, reflected that the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident was incontinent for bowels and bladder. Record review of Resident #18's Comprehensive Care Plan, dated 01/14/2026, reflected that the resident was incontinent and one of the interventions was to clean the perineal area with each incontinent care. During an observation on 03/04/2026 at 12:30 PM revealed CNA H was about to do incontinent care for Resident #18. CNA H grabbed some gloves from a box on the wall and put them inside her pockets. She then proceeded with incontinent care. When she changed her gloves, it was observed that she pulled a pair of gloves from her left pocket and used them to continue cleaning the resident. During an interview on 03/04/2026 at 12:47 PM, CNA H said she should not put gloves in her pockets because she was not sure if her pocket was clean. She said she guessed her pocket was not clean because she would put her keys and cell phone in her pocket. She said she would not put gloves inside her pocket again and would just get them from the box to make sure she was using clean gloves during incontinent care. 3. Record review of Resident #93's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #93's Comprehensive MDS Assessment, dated 01/31/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #93's Comprehensive Care Plan, dated 02/08/2026, reflected the resident required EBP for having a g-tube and one of the interventions was to provide patient with standard precaution when providing hygiene. Record review of Resident #93's Physician Order, dated 01/31/2025, reflected Enteral (pertaining to the stomach) Feed Order every shift related to GASTROSTOMY STATUS (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support) Enteral: Enteral Nutrition Novasource Renal at 50 ml per hour for 24 hours via pump. Record review of Resident #93's Physician Order, dated 06/01/2024, reflected Dialysis: Send approved snack with resident on dialysis days every day shift every Mon, Wed, Fri get snack from dietary to send with resident. During an observation on 03/03/2026 at 11:16 AM revealed CNA G shaving Resident #93's face. CNA G was not wearing a gown while providing hygiene and was leaning directly to the resident's bed. It was observed that there was a sign outside the resident's room that the resident was on enhanced barrier precautions, and PPE was required when providing hygiene. 4. Record review of Resident #93's Comprehensive Care Plan, dated 02/08/2026, reflected the resident required EBP for having a g-tube and one of the interventions was to provide patient with standard precaution when dressing. During an observation on 03/03/2026 at 11:29 AM revealed CNA G and COTA I were changing Resident #93's clothing. CNA G and COTA I were not wearing gowns while dressing the resident. It was observed that there was a sign outside the resident's room that the resident was on enhanced barrier precautions and PPE were required during dressing. It was observed that ADON A went inside the room and told CNA G and COTA that they need to wear gowns. During an interview on 03/03/2026 at 11:31 AM, CNA G said Resident #93 was on EBP because the resident had a g-tube and was undergoing dialysis. She said there was a sign outside the resident's room to remind the staff to wear a gown in addition to gloves to prevent cross contamination. She said when a resident was on EBP, it meant that a gown was required when doing any ADL such as hygiene and dressing. She said she did not know why she forgot to wear a gown. She said since ADON A reminded her she needed to wear a gown; she would wash her hands and would get a gown. During an interview on 03/03/2026 at 11:33 AM, COTA I said she was just helping CNA G but should have worn a gown because the resident had a g-tube and was undergoing dialysis. She said gowns were required to prevent introducing any microorganisms to residents with tubing like the g-tube and the dialysis shunt (surgically created connection between the blood vessels). During an interview on 03/03/2026 at 12:45 PM, ADON A said she saw CNA G and COTA I were not wearing gowns when dressing Resident #93. She said there was a sign outside the resident's door reminding the staff to wear a gown when providing hygiene and when changing the resident's clothing. She said if the resident was on EBP then the staff should wear a gown to prevent transfer of microorganism from one resident to another. 5. During an observation on 03/03/2026 at 12:01 PM revealed RN C was passing plates in the dining area. It was observed that he was not doing hand hygiene between plates. He did it five times. During an interview on 03/03/2026 at 12:15 PM, RN C said he was not aware he was not doing hand hygiene when he was passing plates. He said the best practice was to sanitize the hands after placing a plate for a resident whether he touched the resident or not. He said not sanitizing hands between plates could result in cross contamination. 6. During an observation on 03/03/2026 at 12:05 PM revealed CNA J was assisting feeding two residents in the dining area. It was observed that she was not doing hand hygiene between assisting the residents. She was observed to assist for over 5 minutes. During an interview on 03/03/2026 at 12:10 PM the DON stated that staff were seen assisting two residents simultaneously to eat lunch and she was aware that was a risk to the residents. The DON stated there could have been the spread of infection from one resident to another resident from lack of hand hygiene. The DON stated she would give the staff members who assist residents with meals hand sanitizer to use when assisting more than one resident at a time. During an interview with CNA J on 03/03/2026 at 1:25 PM, the CNA stated that hand sanitizer should have been used between assisting each resident in order to avoid cross contamination between the residents. CNA J stated that she was focused on making sure to not confuse the resident's utensils. CNA J stated that it was best to ask another staff member for help and to not attempt to assist two residents at the same time with meals. During an interview on 03/05/2026 at 6:45 AM, ADON A said gloves should not be placed inside the pockets because the pockets were dirty, rendering the gloves dirty when used during incontinent care. She said the cups that had contact with the resident's overbed table should have been thrown away and not placed inside the drawer because of possible cross contamination. She also said hand hygiene should be performed when passing plates for the same rationale. She said the issues discussed contributed to probable infection. She said the expectation was for the staff to be mindful of what they were doing to protect the residents. She said the DON had already started an in-service about infection control, hand washing, and EBP. During an interview on 03/05/2026 at 7:11 AM, the Administrator said that the expectation was for the staff to wear gowns in addition to the gloves if the residents were on EBP, not to put gloves in their pockets, to not put anything on the cart from the resident's room, and to perform hand hygiene when passing plates during meal times. He said the concerns discussed would all contribute to the development and spread of infection. He said he was not a clinician and would let the DON take the lead on the issue of infection control. During an interview on 03/05/2026 at 7:39 AM, the DON said if a resident was on EBP, then the staff doing care or treatment should wear a gown every time they had contact with the resident. She said residents with g-tube and dialysis shunt catheter were on EBP and required PPE to prevent the spread of infection from one resident to another. She said there might be no policy that would say not to put the gloves in the pockets, but the best practice was not to put gloves inside the pockets to make sure the gloves being used were clean. She said it was also an infection control issue if the staff did not sanitize their hands between plates. She said she already started an in-service about infection control and hand hygiene. In an interview on 03/05/2026 at 9:46 AM, ADON B said she was the Infection Preventionist of the facility. She said she was made aware of the issue of infection control. She said anything that was taken inside the resident's room should be discarded and not placed inside the cart. She said gowns should be worn if the residents were on EBP. She said there were signs outside the residents' rooms to remind the staff when they were supposed to wear gowns in addition to the gloves. She said gloves were not supposed to be inside the pockets of the staff because their pockets could be dirty. She said hand hygiene was required when passing plates as well. She said the DON already started an in-service, and she would be closely monitoring the staff's adherence to the policies of infection control, hand hygiene, and EBP. She said the facility might not have a policy regarding not putting gloves in their pockets and not putting anything from the resident's room in the cart, but the best practice was not to do them because the outcome could be cross contamination. Record review of the facility's policy Enhanced Barrier Precautions (Orientation Tool) undated, reflected Enhanced Barrier Precautions (EBP}: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO (Multi-Drug Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing . Examples of Enhanced Based Precaution residents . Indwelling medical devices . feeding tubes . Enhanced-Based Precautions are indicated during . Dressing . providing hygiene. Record review of the facility's policy Handwashing/Hand Hygiene 2001 MED-PASS, Inc. revised December 22, 2023, reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub . o. Before and after eating or handling food . p. Before and after assisting a resident with meals.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two residents (Residents #93) reviewed for feeding tube management. The facility failed to ensure Resident #93 had orders to flush the g-tube before and after medication administration, to check the placement, and to check the residual on 03/04/2026. These failures could place residents with g-tubes at risk for tube displacement, clogging, aspiration, and discomfort.Findings included: Record review of Resident #93's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #93's Comprehensive MDS Assessment, dated 01/31/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had a feeding tube (medical device that helps deliver nutrition and medication directly to the person's stomach). Record review of Resident #93's Comprehensive Care Plan, dated 02/08/2026, reflected the resident received required tube feeding and one of the interventions was to check residual (food, liquid, and secretions remaining in the stomach) and placement before initiation of formula, medication administration, and flushing the g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to check for tube placement. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to check for gastric residuals. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to flush before and after medication administration. During an observation and interview on 03/03/2026 at 11:16 AM revealed Resident #93 was in his bed awake. It was observed that the resident had g-tube on his upper left abdomen. The resident said he had an issue with swallowing; that was why he had a g-tube. During an observation on 03/04/2026 at 11:45 AM revealed RN C was about to administer Resident #93's medication via g-tube. He sanitized his hands, put the medication in a small plastic cup, crushed it, returned the crushed medication to the small plastic cup, and dissolved it with 10 cc of water. He then went inside the resident's room and placed the crushed medication and some water on the resident's overbed table. He washed his hands and put on a gown and a pair of gloves. He took a 60 ml piston syringe from a plastic bag hanging in an IV pole and placed it also on the overbed table. He raised the bed, elevated the head of the bed, turned off the machine, and disconnected the g-tube from the formula. After disconnecting the g-tube, he pulled the plunger out of the syringe halfway and checked for the placement and the gastric residual. After checking for the placement and the gastric residual, he pulled the plunger of the syringe and attached it to the g-tube. After attaching the barrel of the syringe to the g-tube, he flushed the g-tube with 30 cc of water, poured the dissolved medications, and flushed it again with 30 cc of water. After he was done administering the medications, he detached the syringe and cleaned the table and the syringe. During an interview on 03/04/2026 at 12:19 PM, RN C said he flushed before and after medication administration to make sure the g-tube was patent (unobstructed), checked the placement and the residual to see if the tube was not dislodged and that the resident's stomach had no problem with absorption. When asked if the resident had an order for flushing the g-tube, checking for placement, and checking for the residual, RN C checked his computer for the order and said there were no orders for flushing the g-tube, checking for placement, and checking for the residual. He said he knew what to do, but there should be an order for flushing the g-tube, checking for placement, and checking for the residual. He said this should have been caught by whoever was administering the resident's medications, so orders were put in place. He said he was partly at fault because he did not check if the resident had appropriate orders. He said there should be an order for everything done for the resident to ensure continuity of care. He said he would just finish what he was doing and then transcribe the orders. During an interview on 03/05/2026 at 6:45 AM, ADON A said there should be orders for everything done for the residents. She said even though the nurses knew what to do, there should be an order in the resident's profile pertaining to the flushing, checking for placement, and checking for residuals. She said it was an oversight for those administering the resident's medications, and it was also an oversight on her part because she was supposed to check the orders as well. She said the expectation was for the staff to check for g-tube placement and to check if appropriate orders were in place. She said she would be doing a one-on-one with the nurses regarding putting orders in the system. She said she would coordinate with the DON regarding an in-service about enteral feeding and physician orders. During an interview on 03/05/2026 at 7:11 AM, the Administrator said he was not a clinician and would let the DON take the lead on the issue. He said the expectation was if orders for g-tube were needed, then there should be orders in the residents' profile. During an interview on 03/05/2026 at 7:39 AM, the DON said the expectation was orders to be inputted in the residents' eMAR or eTAR and would be followed correctly. She said the placement of the g-tube and the gastric residual should be checked to prevent aspiration. She said the g-tube should be flushed before and after to make sure the g-tube was working. She said even though the staff did the right procedure and knew that the g-tube needed flushing before and after administering medications via g-tube, there should still be orders for flushing, checking for placement and gastric residual. She said, new nurses might not be familiar with how to administer medications via g-tube and end up not flushing, not checking for placement, and not checking for residuals, and then they would wonder why the g-tube was clogged. She said she would start an in-service regarding g-tube and physician orders. Record review of the facility's policy Administering Medications through an Enteral Tube 2001 MED-PASS, Inc., revised July 5, 2019, reflected Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Preparation . 1. Verify that there is a physician's medication order for this procedure . Steps in the Procedure . 11. Confirm placement of feeding tube . 13. Check gastric residual volume (GRV) to assess tolerance of enteral feeding . 14. When correct tube placement and acceptable GRV have been verified, flush tubing . 20. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of tap water or prescribed amount.

Based on observation, interview, 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 two of twelve residents (Resident #6 and Resident #128) reviewed for respiratory care. 1. The facility failed to ensure Resident #6's Yankauer suction tip connected to the suction machine was properly stored on 03/03/2026. 2. The facility failed to ensure Resident #128's nasal cannula connected to the oxygen concentrator was properly stored on 03/03/2026. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.Findings included: 1. Record review of Resident #6's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (blockage in the blood vessels of the brain). Record review of Resident #6's Comprehensive MDS Assessment, dated 02/19/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a cerebral infarction and was admitted to hospice. Record review of Resident #6's Comprehensive Care Plan, dated 02/15/2026, reflected that the resident had a terminal prognosis related to cerebral infarction, was admitted to hospice, and had impaired gas exchange (disruption in the exchange of gases in the lungs). The interventions were to initiate oxygen therapy at 2 - 5 L/min per nasal cannula as needed and to suction as needed. Record review of Resident #6's Physician Order, dated 04/25/2025, reflected Suction as needed. During an observation and interview on 03/03/2026 at 9:29 AM revealed Resident #6 was in his bed, awake. It was observed that there was a suction machine on top of the resident's drawer. A Yankauer suction tip (oral suctioning tool used to remove fluid and secretions from the airway) was connected to the tubing of the suction machine. The suction tip was behind the suction machine and was laying on top of the table. The suction tip was not bagged. When asked about his suction machine, the resident did not reply. During an observation and interview on 03/03/2026 at 9:38 AM, RN B said Resident #6 was a hospice resident, and the hospice was the one who provided the suction machine. She said the suction tip should be bagged when not in use to prevent cross contamination. She said the issue was not if the resident was using it or not, but if it was kept clean in case the resident needed it. She disconnected the suction tip, threw it, and said she would get another suction tip and would put it inside a bag. 2. Record review of Resident #128's Face Sheet, dated 03/03/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #128's Comprehensive MDS Assessment, dated 02/20/2026, reflected that the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 09. The Comprehensive MDS Assessment reflected the resident had sleep apnea and was using oxygen. Record review of Resident #128's Comprehensive Care Plan, dated 02/04/2026, reflected the resident had altered respiratory status/difficulty breathing r/t sleep apnea and one of the interventions was oxygen setting: O2 via n/c @2 lpm at night. Record review of Resident #128's Physician Orders, dated 01/30/2026, reflected Oxygen delivery at nighttime 2 liters via nasal cannula at bedtime for oxygen. During an observation and interview on 03/03/2026 at 9:09 AM revealed Resident #128 was in her bed awake. It was observed that an oxygen concentrator was at bedside with a nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to it. The nasal cannula was hanging on top of the oxygen concentrator and was not bagged with the prongs of the nasal cannula almost touching the floor. The resident said she would only use her oxygen at night. She said she was the one who took it off and gave it to the nurse. During an observation and interview on 03/03/2026 at 9:45 AM, LVN D said whoever the staff that the resident handed over the nasal cannula should have placed it inside a plastic bag to prevent cross contamination. LVN D disconnected the nasal cannula and threw it in the trash can. She said she would get a new one and would put it in a plastic bag, so the resident would use a clean one for her next use. During an interview on 03/05/2026 at 6:45 AM, ADON A said the nasal cannula and the Yankauer should be bagged whenever the residents were not using them to prevent cross contamination and eventually infection. She said the nasal cannula was inserted into the nose and the Yankauer to the mouth, and if they were dirty, it was just like introducing germs to the inside of the body. She said the expectation was for the staff to ensure the equipment used for respiratory care was properly stored. She said she would coordinate with the DON to do an in-service about bagging the nasal cannula and the Yankauer when not in use. During an interview on 03/05/2026 at 7:11 AM, the Administrator said everything the residents were using should be kept clean to prevent infection. He said he was not a clinician and would let the DON take the lead on the issue. During an interview on 03/05/2026 at 7:39 AM, the DON said the nasal cannula and the yankauer were supposed to be in a bag when the residents were not using them to prevent cross contamination and respiratory infections. She said, they might not have policy for the suction tip but the policy for bagging the nasal cannula could be applied as well to the suction tip. She said the expectation was for the staff to be mindful and make sure the nasal cannula and the yankauer were kept clean and bagged when the residents were not using them. She said she would conduct an in-service about respiratory care. Record review of the facility's policy, Oxygen Use (Respiratory Therapy) - Prevention of Infection 2001 MED-PASS, Inc. revised November 2011, reflected Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . Steps in the procedure . Infection Control Considerations Related to Oxygen Administration . 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use.

Based on observation, interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two residents (Resident #9 and Resident #93) reviewed for dialysis. 1. The facility failed to ensure Resident #9 had orders for ongoing assessment of the resident's condition before and after dialysis treatments received at a certified dialysis facility. 2. The facility failed to ensure Resident #93 had orders for ongoing assessment of the resident's condition before and after dialysis treatments received at a certified dialysis facility. These failures could place residents undergoing dialysis at risk for proper assessment not done that could result in hypotension (abnormally low blood pressure), bleeding, and clotting of dialysis site.Findings included: 1. Record review of Resident #9's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with end stage renal disease (a condition where the kidneys can no longer function adequately). Record review of Resident #9's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/06/2026, reflected the resident was cognitively intact with a BIMS (screening tool used to assess cognitive status) score of 15. The Comprehensive MDS Assessment indicated the resident was undergoing dialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function). Record review of Resident #9's Comprehensive Care Plan, dated 01/25/2026, reflected the resident went to dialysis Monday, Wednesday, and Friday due to renal failure (kidneys were not functioning) and one of the interventions was check and change dressing daily at access site. Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order to monitor the dialysis site. Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order for her dialysis appointment. Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order to obtain vital signs post dialysis. Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order to remove pressure dressing to dialysis site post dialysis. Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order to check bruits (sound produced by the blood flow) and thrills (vibration that could be felt over the dialysis site). Record review on 03/05/2026 of Resident #9's Physician Order reflected that the resident did not have an order to refrain from getting the blood pressure or finger stick from the arm with a shunt (surgically created connection between the artery and the veins). During an observation and interview on 03/03/2026 at 11:21 AM revealed Resident #9 was in her wheelchair and was eating lunch. She said she would go to a dialysis session every other day. 2. Record review of Resident #93's Face Sheet, dated 03/05/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with end stage renal disease. Record review of Resident #93's Comprehensive MDS Assessment, dated 01/31/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident was undergoing dialysis. Record review of Resident #93's Comprehensive Care Plan, dated 02/08/2026, reflected the resident received hemodialysis (medical treatment that filters waste and excess fluids from the blood when the kidney can no longer function) and one of the interventions was to send approved snack with resident on dialysis days. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to monitor dialysis site. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order for his dialysis appointment. Record review on 03/05/2026 of Resident #93's Physician Order reflected the resident did not have an order to obtain vital signs post dialysis. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to remove pressure dressing to dialysis site post dialysis. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to check bruits and thrills. Record review on 03/05/2026 of Resident #93's Physician Order reflected that the resident did not have an order to refrain from getting the blood pressure or finger stick from the arm with a shunt (connection between the artery and the veins). During an observation and interview on 03/03/2026 at 11:16 AM revealed Resident #93 was in his bed, awake. It was observed that the resident had a shunt to his right upper arm. The resident said his kidneys were not functioning anymore; that was why he was receiving dialysis for almost two years. During an observation and interview on 03/04/2026 at 7:52 AM, ADON A said if a resident was undergoing dialysis using an outside dialysis clinic, the facility was responsible in assessing the resident when the resident came back to the facility. She said the dialysis site should be assessed for any bleeding, for signs and symptoms of infection, and for bruits and thrills. When asked if the residents had orders for the mentioned assessments, ADON A turned on her computer and went to Resident #93's profile and saw that the resident did not have any orders pertaining to dialysis except for sending approved snack during dialysis appointment. She then opened Resident #9's profile and said Resident #9 also did not have any orders for dialysis. She said the nurses knew what to do, but there should be orders in everything done for the residents. She said the orders were transcribed to make sure the care or treatment was being done. She said the orders should be in the residents' eTAR to remind the staff what to do and assess for residents undergoing dialysis. She said the residents could be in danger of hemorrhage and infection if the dialysis site was not assessed. She said what might have happened was when the residents went to the hospital; the orders were discontinued but when the residents were re-admitted back to the facility, all the orders for dialysis should have been put back in the residents' profile. ADON A started to put the orders for dialysis for Resident #93 and Resident #9. She said she would coordinate with the DON to do an in-service about dialysis care. During an interview on 03/04/2026 at 11:13 AM, RN B said she noticed that there were no orders for Resident #9's dialysis, but she forgot to inform the ADON or forgot to put the orders. She said there should be orders for dialysis because new nurses might not be able to assess the dialysis site because they did not see any orders for dialysis care. During an interview on 03/04/2026 at 12:19 PM, RN C said he was the one sending Resident #93 out for dialysis. He said he did not notice the orders because the resident would come back to the facility on the next 2 PM to 10 PM shift. He said, but that was not an excuse. He said orders for assessing the dialysis site and the precautions should be in the residents' profile to make sure that the resident was being taken care of. During an interview on 03/05/2026 at 7:11 AM, the Administrator said he was not a clinician and would let the DON take the lead on the issue. He said the expectation was if orders for dialysis were needed, then there should be orders in the residents' profile. During an interview on 03/05/2026 at 7:39 AM, the DON said the expectation was orders to be inputted in the residents' eMAR or eTAR and would be followed correctly. She said the issue was not about if the nurses knew what they were supposed to do, but about not putting the orders for dialysis that could eventually affect the care being given to the residents undergoing dialysis. She said the nurse admitting the residents were responsible in putting up the orders, and the ADONs were responsible in checking the residents' profile the following day. She said orders should be transcribed to ensure assessment and care for the dialysis of residents were being done. She said she would start an in-service regarding dialysis of care and physician orders. Record review of the facility's policy End-Stage Renal Disease, Care of a Resident with 2001 MED-PASS, Inc. revised September 2010 reflected Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . Policy Interpretation and Implementation . 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents . 2. Education and training . a. The nature and clinical management of ESRD (including infection prevention and nutritional needs) . b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis . c. Signs and symptoms of worsening condition and/or complications of ESRD . d. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections . f. Tinting and administration of medications, particularly those before and after dialysis . g. The care of grafts (tube used to connect the blood vessels) and fistulas (an access made between the blood vessels). Record review of the facility's policy Medication and Treatment Orders 2001 MED-PASS. Inc. revised July 2016 reflected Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing . Policy Interpretation and Implementation . 1. Medications-shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart . 9. Orders for medications must include . a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy .c. Dosage and frequency of administration . d. Route of administration .e. Clinical condition or symptoms for which the medication is prescribed . f. Any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.).

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eighteen residents (Resident #126) reviewed for pharmaceutical services. The facility failed to ensure MA F did not leave Resident #126's medications inside the resident's room for the resident to administer unattended on 03/03/2026. This failure could place residents at risk of not receiving medications as ordered, taking medications without a self-administration assessment, potential overdose, and adverse effect.Findings included: Record review of Resident #126's Face Sheet, dated 03/03/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar) and hypertension (high blood pressure). Record review of Resident #126's Comprehensive MDS Assessment, dated 03/06/2026, reflected the resident had severe impairment in cognition with a BIMS of 07. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and hypertension. Record review of Resident #126's Comprehensive Care Plan, dated 03/02/2026, reflected that the resident had diabetes mellitus and hypertension and the intervention for both was to administer medications as ordered. Record review of Resident #126's Physician's Order, dated 03/03/2026, reflected Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN Hold for sbp less than 110, HR less than 60. Record review of Resident #126's Physician's Order, dated 03/02/2026, reflected Metformin HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM. Record review on 03/03/2026 of Resident #126'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 03/03/2026 at 9:17 AM revealed Resident #126 was in his bed, awake. It was observed that there were two dry pills on the resident's overbed table. According to the resident, the staff gave him the pills and told him to take the pills when he was done eating his candy. He said he knew one of the medications was for his blood pressure, but he forgot what the other pill was for. He said he was new in the facility and still did not know if the staff that gave him the medications was a nurse or the medication aid. During an observation and interview on 03/03/2026 at 9:21 AM, MA F said when administering medications, staff should make sure the medications were taken before leaving the residents' rooms. She said she thought the resident took the pills. She said she should have stayed with the resident until the resident had taken all the medications. She said the pills should not be left with the residents because the residents might not take them, throw them, or choke while taking them, and no one would know. She said other residents or visitors might be able to get hold of the medication and consume them and allergic to the said medications. She went inside Resident #126's room and asked the resident if he already took the medications. During an interview on 03/03/2026 at 9:38 AM, RN B said MA F told her about the medications that were left inside Resident #126's room. She said not to leave any medications inside the room for the resident to take later because the resident might forget to take them and then consume them with the next batch of same medications that could result in overdose. During an interview on 03/05/2026 at 6:45 AM, ADON A said staff should not leave any medications with the residents for the residents to take unsupervised. She said the staff administering the medications should stay with the resident until the resident was done with the medications. She said the resident might not take them, or someone else might, like another resident or a visitor. She said the resident might aspirate or choke while taking the medications, and nobody would know. She said the residents could not take medications by themselves except if they were assessed that they could self-administer. She said she would coordinate with the DON to do an in-service about not leaving the medications with the residents. During an interview on 03/05/2026 at 7:11 AM, the Administrator said the expectation was the staff would not leave medications with the residents unattended because of the risk of the resident not taking them or the pills not being taken on time. He said he was not a clinician and would let the DON take the lead on the issue. During an interview on 03/05/2026 at 7:39 AM, the DON said staff should never leave the medications at the bedside for the resident to take later. She said the staff must ensure the resident took his medications before leaving the room. She said the resident could hoard or hide the pills to avoid taking them, could overdose on hoarded pills, and could choke without anybody to help the resident. She said the expectation was that no residents were administering their medications without proper assessment. The DON said she would have an in-service about not leaving pills inside the rooms. 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 . 23. Residents may self-administer their own medications only if . had determined that the decision - making capacity to do so safely.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of four direct care staff (RN C) reviewed for other environmental conditions. The facility failed to ensure that RN C did not leave a container of germicidal wipes on top of the nurse's cart unattended on 03/04/2026. This failure could result in having an environment that was not safe for the residents, staff, and public. Findings included: During an observation on 03/04/2026 at 11:41 AM revealed a container of germicidal wipes (substance that destroys germs and microorganisms) was on top of an unattended cart parked in the hallway. It was observed that several residents were passing by the hallway. During an observation on 03/04/2026 at 11:45 AM revealed RN C went inside a resident's room to administer medications. He closed the door while administering medications. He left his cart outside the resident's room with the container of germicidal wipes still on top of his cart. The container of germicidal wipes was left unattended until he finished giving medications. During an observation and interview on 03/04/2026 at 12:19 PM, RN C said he should have placed the germicidal wipes inside the cart before leaving the cart to go to the nurse's station and before he closed the door to give medications because residents might be able to get hold of the wipes and use them to clean their faces and eyes that could result in irritations. He took the container of germicidal wipes and put it inside the last drawer of the cart he was using. During an interview on 03/05/2026 at 6:45 AM, ADON A said the germicidal wipes should be stored inside the cart for safety reasons. She said residents might think they were ordinary wipes and use them to clean their eyes, nose, ears, and skin. She said it might cause irritation and toxicity. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. She said she would coordinate with the DON to do an in-service about not leaving the germicidal wipes on top of the carts. During an interview on 03/05/2026 at 7:11 AM, the Administrator said the germicidal wipes should be placed somewhere not accessible to the residents. He said if the wipes had chemicals in them, that could be harmful when consumed or had contact with the eyes. He said he would coordinate with the DON to start an in-service about properly storing germicidal wipes. During an interview on 03/05/2026 at 7:39 AM, the DON said the germicidal wipes should be locked inside the carts and not left on top of the cart when not in use. She said it should be secured inside the carts so that the residents would not be able to access the wipes that had chemicals on them. She said confused residents might get hold of the wipes and wipe their face and body that could result in irritations. She said the expectation was for the staff to be mindful and never leave the germicidal wipes on top of the carts unattended. She said she would start an in-service about storing the germicidal wipes properly. Record review of the facility's policy Storage of Medications 200 I MED-PASS. Inc. revised April 2019 reflected Policy Statement: The facility stores all drugs and biologicals in a safe . 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. Record review of Safety Data Sheet (SDS) dated 01/21/2026 reflected Safety Data Sheet Medline Micro-Kill Two Germicidal Wipes . Section 2. Hazards Identification . Classification . acute toxicity - oral . eye irritant . flammable liquids . Hazard Statements: Causes serious eye irritation . Flammable liquid and vapor . May cause drowsiness or dizziness . Storage: Keep out of the reach of children.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 3 of 15 residents (Residents #3, #4 and #5) reviewed for nutrition. 1. The facility did not ensure Resident #3 was given double protein portion as ordered by the physician. 2. The facility did not ensure Resident #4 was given ice cream and a shake as ordered by the physician. 3. The facility did not ensure Resident #5 was given a shake as ordered by the physician. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity.Findings Included: 1. Record review of Resident #3's face sheet, dated 11/19/25, reflected Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included hemiplegia (paralysis that effects on side of the body) affecting left non dominant side. Record review of the nutrition/dietary note dated 04/08/25 reflected the dietician recommended adding enhanced and double protein portions with meals. Record review of Resident #3's quarterly MDS assessment, dated 10/02/25, reflected Resident #3 usually made himself understood, and usually understood others. Resident #3's BIMS score was 6, which reflected his cognition was severely impaired. Resident #3 required set-up or clean up assistance with eating. Resident #3 has not had 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #3's undated comprehensive care plan reflected Resident #3 had potential nutritional problems related to adult failure to thrive, dysphagia (difficulty swallowing), and GERD (acid reflux). The care plan interventions included: provide, serve diet as ordered. Record review of Resident #3's order summary report, dated 11/19/25, reflected regular diet, pureed texture, regular consistently, enhanced and double portions with meals with a start date 11/12/24. During an observation and record review on 11/17/26 at 11:47 a.m., Resident #3 received a single serving of the entree which was golden fried chicken. The meal ticket reflected double portions. During an interview on 11/17/25 at 12:40 p.m., [NAME] D stated he should have gotten two servings of golden fried chicken instead of one. [NAME] D stated, it was a mistake when asked why Resident #3 did not receive double portions. [NAME] D stated it was his responsibility to ensure the trays were correct before serving a resident. [NAME] D stated this failure could potentially put Resident #3 at risk for further weight loss. 2. Record review of Resident #4's face sheet, dated 11/19/25, reflected Resident #4 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included muscle wasting and atrophy (decrease in size of a body part, cell, organ, or other tissue. Record review of the nutrition/dietary note dated 04/29/25 reflected the dietician recommended ice cream and house shake with lunch. Record review of Resident #4's quarterly MDS assessment, dated 11/13/25, reflected Resident #4 made herself understood, and understood others. Resident #4's BIMS score was 12, which reflected her cognition was moderately impaired. Resident #4 required set-up or clean up assistance with eating. Resident #3 has not had 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #4's comprehensive care plan, revised on 09/23/25, reflected Resident #4 had a history of unplanned/unexpected weight loss. The care plan interventions included: give the resident supplements as ordered. Record review of Resident #4's order summary report, dated 11/19/25, reflected mechanical soft texture, regular consistency. add shake and ice cream at lunch with a start date 09/04/25. During an observation and record review on 11/17/26 at 11:45 a.m., Resident #4 did not receive ice cream nor a shake with her lunch meal. The meal ticket reflected add shakes and ice cream at lunch. 3. Record review of Resident #5's face sheet, dated 11/19/25, reflected Resident #5 was an [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included active primary progressive multiple sclerosis (chronic autoimmune disease that affects the central nervous system). Record review of the nutrition/dietary note dated 06/23/25 reflected the dietician recommended house shakes BID between meals. Record review of Resident #5's quarterly MDS assessment, dated 11/06/25, reflected Resident #5 usually made herself understood, and usually understood others. Resident #5's BIMS score was 9, which reflected her cognition was severely impaired. Resident #5 required set-up or clean-up assistance with eating. Resident #5 has not had 5% weight loss or more in the last month or loss of 10% or more in last 6 months. Record review of Resident #5's comprehensive care plan, revised on 05/20/25, reflected Resident #5 had unplanned/unexpected weight loss related to poor fluid intake. The care plan interventions included: give the resident supplements as ordered. Record review of Resident #5's order summary report, dated 11/19/25, reflected regular texture, regular/thin consistency with a start date 04/03/24. The order summary report did not reflect shakes at lunch and dinner. During an observation and record review on 11/17/26 at 11:50 a.m., Resident #5 did not receive a shake with her lunch meal. The meal ticket reflected add shake at lunch and dinner. During an interview on 11/17/25 at 12:45 p.m., RN E stated she was responsible for ensuring residents receive the correct diet. RN E stated Residents #3, #4, and #5 trays were not reviewed by this nurse because the aides had already started passing the trays out before she got in the dining room. RN E stated the aides should have waited for her to come in prior to passing out trays. RN E stated it was important for residents to receive the correct diet to ensure that everything was given and prevent weight loss. During an interview on 11/17/25 at 12:52 p.m. CNA F stated the nurse was in the dining room when she passed the trays to the residents. CNA F stated the nurse must check the trays prior to passing them out to the residents to make sure the residents received the right diet and the proper meals that were ordered. CNA F stated she did not pass out the three residents that did not receive double portions or the shake/ice cream. CNA F stated it was important residents received the correct to prevent weight loss and right nutrition. During an interview on 11/17/25 at 12:58 p.m., MA G stated she did not assist with passing trays during dining. MA G stated she came in to assist another resident with their meal. During an interview on 11/17/25 at 1:04 p.m., MA H stated she did not pass out trays prior to the nurse checking them. MA H stated she did not pass out the three residents that were observed with no double meat nor mighty shake/ice cream. MA H stated when trays were passed out the nurse was already in the dining room. MA H stated it was important to ensure the residents received the correct diet to prevent weight loss. During an interview on 11/17/25 at 1:30 p.m., CNA K stated she did not pass out any trays before the nurse came in. CNA K stated she always waited until the nurse looked over the tray to ensure the residents had received the correct diet. CNA K stated she did not pass out the three residents that did not receive double portion nor mighty shake/ice cream. CNA K stated it was important to ensure the residents received the correct diet to prevent weight loss. During an interview on 11/19/25 at 4:55 p.m., the Dietary Manager stated the cook was responsible for ensuring the residents receive two servings of the protein (meat). The Dietary Manager stated the nurse that was in the dining room checking trays for accuracy was responsible for ensuring the residents receive shakes and ice cream. The Dietary Manager stated he monitored meals by random rounds. The Dietary Manager stated there has not been any issues in the past 3 months regarding residents not receiving the correct diet. The Dietary Manager stated it is important to ensure the residents were on the correct diet to prevent weight loss. During an interview on 11/19/25 at 5:45 p.m., the DON stated she expected the physician diet order to be followed. The DON stated some residents did not get their shakes with their meals because the staff like to encourage them to get their calories through their main meal first. The DON stated there was not a list of residents whose staff knew who to encourage to eat their main meal first between receiving a shake. The DON stated the nurse that was circulating the dining room should be monitoring to make sure they received them prior to the end of the meal service. The DON stated she monitored by random rounds to ensure diet orders were followed. The DON stated there has not been any issues in the past. The DON stated it was important to receive the correct diet to help maintain their weight. During an interview on 11/19/25 at 6:13 p.m., the Administrator stated she expected the diet order to be followed. The Administrator stated they should have received their shakes/ice cream with their meals. The Administrator stated she should have received two servings of proteins. The Administrator stated the cook was responsible for ensuring Resident #3 received double portions and the nurse was responsible for ensuring the residents received the shakes/ice cream. The Administrator stated the ADON/DON was responsible for monitoring and overseeing meal service. The Administrator stated it was important to receive the correct diet to prevent weight loss. Record review of the facility's policy titled Menus revised 10/2008 indicated. Menu shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed.

Based on interview and record review the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 2 residents (Resident #2) reviewed for PASARR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.Findings included:Record review of Resident #2's face sheet, dated 11/19/25, reflected Resident #2 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included major depressive disorder and anxiety. Record review of Resident 2's significant change in status, dated 04/07/25, reflected Resident #2 rarely/never made herself understood and rarely/never understood others. The assessment reflected Resident #2 cognitive skills for daily decision making was severely impaired. Record review of the PCSP meeting dated 06/10/24 indicated that a customized manual wheelchair was recommended for Resident #2. Record review of Resident #2's EMR dated 11/18/25 indicated Resident #2 passed away on 04/09/25 at the facility on hospice. During a telephone interview on 11/18/25 at 11:17 a.m., the complainant stated the facility failed to ensure Resident #2 received a customized wheelchair 20 days after the IDT meeting on 06/10/24. During an interview on 11/18/25 at 12:10 p.m., the MDS Coordinator stated it was never a request for a wheelchair. The MDS Coordinator stated the only time Resident #2 got out of bed was for her to sit in the recliner. The MDS Coordinator stated after the IDT meeting, she entered the information into the portal and then the Habitation Coordinator reviewed the information and signed off as completed. The MDS Coordinator stated the next step should have been to get with the DOR and discuss getting the DME company out to fit the resident for an appropriate chair. The MDS Coordinator stated she had 20 business days to submit the NFSS form to the portal. The MDS Coordinator stated that the resident, nor the family requested a wheelchair, she entered it incorrectly that a wheelchair was recommended. The MDS Coordinator stated Resident #2 was using the facility chair, and it met her needs. The MDS Coordinator stated she noticed the error after surveyor intervention. The MDS Coordinator stated it was important to complete the NFSS in time for continuity of care. During an interview on 11/18/25 at 12:31 p.m., the DOR stated the OT was already in the process of getting her a personalized wheelchair through a DME company. The DOR stated the family wanted her to get up more often and have her mobile. The DOR stated a standard wheelchair would not fit her. The DOR stated the resident received the wheelchair through a DME company. The DOR stated the wheelchair was delivered on 12/24/24. When asked what the reason for the delay in the resident getting the chair, the DOR stated, the facility was trying to file it through Resident #2 insurance source instead of PASRR. The DOR stated she remembered during the meeting, the habilitation coordinator asking the family if they wanted to go through PASRR or a DME company and the family requested to speak to the DME company. During a telephone interview on 11/18/25 at 12:54 p.m., the Habilitation Coordinator stated during the initial PSCP meeting on 06/10/24 a wheelchair was recommended and the family agreed to go through PASRR. The Habilition Coordinator stated she sent an email to the DON, ADON, Social Worker, DOR, and the MDS Coordinator on 10/03/24 informing them that they did not make a request for the customized wheelchair on 06/10/24. The Habilitation Coordinator stated she reached out again via email on 10/08/25 for an update. The Habilition Coordinator stated after following up several times she was notified by the DOR that the facility went through a part B source (DME company) not part A (PASRR). The Habilitation Coordinator stated the facility wheelchair was standard and the one through PASRR fitted specifically to the resident. The Habilition Coordinator stated the facility had 20 business days to initiate the wheelchair process from the IDT meeting on 06/10/24. The Habilition Coordinator stated the risk of not completing the process within the time frame put Resident #2 not having the full QOL she potentially could have. During an interview on 11/19/25 at 5:45 p.m., the DON stated she was not aware of the exact time when the NFSS should be completed after the IDT meetings. The DON stated that it was the MDS Coordinator responsibility to complete the NFSS within the appropriate time frame. The DON stated the Regional Clinical Reimbursement Specialist was responsible for monitoring and overseeing the PASRR process. The DON stated it was important to ensure the residents' needs were met in a timely manner. During a telephone interview on 11/19/25 at 6:05 p.m., the Regional Clinical Reimbursement Specialist stated that the NFSS should be completed 21 days after the IDT meeting. The Regional Clinical Reimbursement Specialist stated that it was the DOR responsibility to complete the NFSS within the appropriate time frame and the MDS Coordinator entered the PSCP into the portal. The Regional Clinical Reimbursement Specialist stated the family had initiated getting a wheelchair through a separate DME company. The Regional Clinical Reimbursement Specialist stated the MDS Coordinator should have gone into the portal and updated the PCSP form that way the PASRR representative would have been notified. During an interview on 11/19/25 at 6:13 p.m., the Administrator stated he was unaware of the time frame that the NFSS should be completed after the IDT meeting. The Administrator stated it was the MDS Coordinator responsibility to complete the NFSS within the appropriate time frame. The Administrator stated the Regional Clinical Reimbursement Specialist was responsible for monitoring and overseeing. The Administrator stated it was important to ensure the information was submitted timely, so the residents receive what they need. Record review of the facility's policy titled Preadmission Screening Resident Review Rules revised 09/03/2021 indicated. Post IDT Meeting Responsibilities.2. The facility will initiate the request for specialized services within 20 business days of the IDT/PCSP meeting.

Based on interview and record review, the facility failed to collaborate with hospice representatives through effective communication for 1 of 2 residents (Resident #1) reviewed for hospice services. The facility failed to communicate with hospice on 08/13/25 when Resident #1 fell, and on 10/17/25 when Resident #1 received bruises. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1. Record review of Resident #1's face sheet, dated 11/21/25, indicated he was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), hypertension (high blood pressure), and stroke. Record review of Resident 1's significant change in status, MDS assessment, dated 08/20/25, indicated Resident #1 was sometimes understood and was sometimes understood by others. Resident #1's BIMS score was a #00, which indicated she was severely cognitively impaired. The MDS indicated Resident #1 required total or extensive assistance with her ADLs. The MDS indicated she was receiving hospice service. Record review of Resident #1's physician orders dated 08/07/25 indicated an order for {name} hospice. Record review of Resident #1's incident report dated 08/13/25 did not indicate that hospice was notified of the fall. The incident did not reveal any injuries. Record review of a complaint intake dated 10/14/25 indicated the hospice company was not being notified of all changes on Resident #1. Record review of Resident #1's incident report dated 10/17/25 did not indicate that hospice was notified of bruises to the left forearm. Record review of Resident #1's comprehensive care plan, dated 11/04/25, revealed Resident #1 had a terminal prognosis related to the diagnosis of dementia with risk for weight loss, developing pressure injuries, constipation, and decline in ADLs. Resident #1 was admitted to {name} hospice. The intervention was for staff to adjust the provision of ADLS to compensate for the residents' changing abilities. Encourage participation to the extent the resident wishes to participate and consult with the physician and Social Services to have Hospice care for the resident in the facility. During a phone interview on 11/17/25 at 2:05 p.m., the Hospice DON said they admitted Resident #1 on 08/07/25. She said the facility should notify them of any changes with Resident #1. She said the RP had mentioned, as well as hospice nurse B, that they were not being notified when the residents had a change, such as a fall or skin changes. The DON looked at the call log and could not see where the facility called hospice on 08/13/25 or 10/17/25. She looked at the nurses' notes for dates of 08/13/25 and 10/17/25 and could not see any documentation on those dates. She said it was important for the facility to notify hospice of any changes so that hospice could assess and correlate care with the facility. During an attempted phone interview on 11/18/25 at 4:53 p.m., LVN C, who completed Resident #1's incident report on 08/13/25, was unsuccessful. During a phone interview on 11/18/25 at 5:00 p.m., LVN A said she did a skin assessment on Resident #1 but could not remember the date on which she identified the bruises. She said she notified the DON but could not recall if she notified hospice. She said she was supposed to notify hospice of any changes for continuity of care. During an interview on 11/19/25 at 6:25 p.m., the DON said she expected the charge nurses to notify hospice of any changes. She said she did not know that hospice was not notified of Resident #1's changes. She said she and the nurse managers were the overseers for ensuring hospice was notified of changes. She said they monitored any changes in the morning meetings, looked at the 24-hour report for any changes and reviewed documentation. She said failure to notify hospice of any changes meant they were not aware and unable to provide care for the residents' needs. During an interview on 11/19/25 at 6:35 p.m., the Administrator said it was the nurse's responsibility to ensure hospice was notified of any changes in the residents. He said the nurse management team was the overseer of the process. He said hospice should be made aware of any changes in the residents to ensure their needs were met. He said failure to notify hospice was a lack of coordination of care. Record review of the facility's policy Hospice Program revised July 2017, indicated the facility was responsible for the following. C. notify hospice about the following changes, (1) a significant change in resident physical, mental, social, or emotional status. D. Communicating with the hospice provider (and documenting such communication) to ensure that the residents needs are addressed and met 24-hours per day.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 4 of 4 resident reviewed for pharmacy services. (Resident's #5, #11, #49, and #50) The facility failed to ensure Resident #11's ordered alprazolam (antianxiety) medication was available for administration on 11/26/2024, 11/27/2024, 11/28/2024, and 11/29/2024, which resulted in 11 missed doses of her antianxiety medication. The facility failed to ensure Resident #50's ordered Letrozole (hormone treatment for breast cancer) medication was available for administration 12/03/2024. The facility failed to ensure Resident #49's tramadol (scheduled ll pain medication) was accurately reconciled on 12/03/2024. The facility failed to ensure Resident #5 was not administered Hydrocodone 10/325 milligrams out of the ordered administration times on 12/04/2024. These failures could place residents at risk to have increased symptoms of anxiety, change in hormonal levels affecting breast cancer, medication errors and loss of medications through drug diversion. The findings included: 1. Record review of the face sheet, dated 12/05/2024, reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behaviors (a group of symptoms affecting memory, thinking and social abilities that interferes with daily life) and generalized anxiety disorder (a mental and behavioral disorder characterized by excessive, uncontrollable, and often irrational worry about events or activities). Record review of the admission MDS assessment, dated 10/22/2024, reflected Resident #11 had clear speech and was understood by others. The MDS reflected Resident #11 was able to understand others. The MDS reflected Resident #11 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #11 had no behaviors or refusal of care. The MDS reflected Resident #11 had an active diagnosis of anxiety disorder. The MDS reflected Resident #11 received an antianxiety medication with a noted indication for use. Record review of the comprehensive care plan, revised 10/23/2024, reflected Resident #11 used antianxiety medication related to anxiety disorder. The interventions included: administer antianxiety medication as ordered by the physician. Record review of the order summary report, dated 12/02/2024, reflected Resident #11 had an order, which started on 10/15/2024, for alprazolam (antianxiety medication) 1 mg by mouth three times a day for anxiety. Record review of the MAR, dated November 2024, reflected Resident #11 refused the 3 PM dose of alprazolam on 11/26/2024. The MAR reflected Resident #11 did not receive the alprazolam on 11/27/2024 at 9 AM, 3 PM, or 9 PM; on 11/28/2024 at 9 AM; on 11/28/2024 at 9 AM; and on 11/29/2024 at 9 AM. There were 7 missed doses of alprazolam documented on the MAR. There were no documented behaviors on the MAR. Record review of the controlled drug record sheet, undated, reflected Resident #11 received the last dose of her alprazolam on 11/26/2024 at 9 AM. Record review of the controlled drug record sheet, dated 11/29/24, reflected Resident #11's alprazolam was given at 11/30/2024 at 8 AM. Resident #11 missed 11 doses of her alprazolam (antianxiety medication). Record review of the administration note, signed and dated 11/27/2024 at 9:09 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. Record review of the administration note, signed and dated 11/28/2024 at 8:59 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. Record review of the administration note, signed and dated 11/29/2024 at 9:22 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. During an observation and interview on 12/02/2024 beginning at 11:32 AM, Resident #11 was sitting on her bed. Resident #11 was pleasant and calm during the interview with her hair neatly combed and clothing without stains or odors. Resident #11 stated she had no problems whatsoever with the care she received at the facility. Resident #11 stated she had an issue during the last week (11/25/24 to 11/30/24) with not receiving her antianxiety medication. Resident #11 stated she felt like she had an anxiety attack because her toes went numb. Resident #11 stated she was going to talk to the doctor about it and was waiting on him to come to the facility. During an interview on 12/02/2024 beginning at 5:47 PM, RN A stated he did not normally work on Resident #11's hallway. RN A stated he worked on Resident #11's hallway on 11/29/2024 and was passing medications. RN A stated he realized Resident #11 was out of her alprazolam, so he notified the pharmacy. RN A said the pharmacy reported they were unable to see the order on their side, so RN A stated he re-entered the order in the computer system to fix it. RN A stated Resident #11 did not receive her alprazolam on 11/29/2024 because it was unavailable at the facility. RN A stated he was unsure how long Resident #11 went without her medication. RN A stated he did not notice if Resident #11 had an increased anxiety or signs of a panic attack. RN A stated resident's who did not receive their antianxiety medication could have had increased anxiety. During an interview on 12/03/2024 beginning at 8:01 AM, RN H stated last week on approximately Thursday (11/28/2024) MA G reported Resident #11 had approximately 2 alprazolam left. RN H stated the psychiatric doctor was at the facility and she believed the doctor was going to send in the refills to the pharmacy. RN H stated to her knowledge Resident #11 did not go without her antianxiety medication. RN H stated she did not notice if Resident #11 had any increased anxiety or signs of a panic attack. RN H stated the process for re-ordering narcotic medication was as follows: when the card got down to about 7 or 8 pills, the MA should have notified the charge nurse. The charge nurse then notified the pharmacy to see if there were any refills available. RN H said if the medication had refills left the charge nurse was able to re-order the medication. RN H stated if no refills were available, then the charge nurse would have notified the agent for the doctor so they could have called in the order to the pharmacy. RN H stated the ADONs were agents for the doctors at the facility. RN H stated the facility had a lot of problems with the pharmacy including sending medication timely. RN H said they also had trouble with getting the agents to call in the refill orders. RN H said that if a resident did run out of their antianxiety medication, she would have notified the doctor to get a STAT order or to see if anything could have been put in place. RN H said if a resident did not receive antianxiety medication, it could have caused a panic attack. RN H said signs of a panic attack included increased heart rate, sweating, agitation, and confusion. During an interview on 12/03/2024 beginning at 8:05 AM, MA G said Resident #11 ran out of her antianxiety medication last week. MA G stated she was unsure what day it was and was unsure how long she went without the medication. MA G stated she notified RN H about 3 days before Resident #11 ran out of medication. MA G stated RN H notified LVN K and LVN K called the medication into the pharmacy. MA G said the last she heard about the medication was that it needed a new prescription, and the pharmacy was waiting on the doctor to send it in. MA G stated alprazolam was not in the e-kit. MA G stated she kept asking and reminding the nurses who worked that she was out, but she was unsure if anything was done. MA G said the process for re-ordering controlled medication was to notify the nurse, then the nurse would have notified the pharmacy to see if any refills were available. MA G said if refills were available the pharmacy would have sent the medication. MA G said if refills were unavailable the nurse would have notified the doctor. MA G said medication aides could not have re-ordered controlled medication. MA G said resident who did not receive their antianxiety medication could have cause anxiety, insomnia, and increased moodiness. During an interview on 12/03/2024 beginning at 8:12 AM, LVN K stated she did not believe it was reported that Resident #11 was out of alprazolam. LVN K stated if a resident ran out of medication, the medication aid should have let the charge nurse know. LVN K said the charge nurse should have notified the pharmacy and checked for refills. LVN K said if refills were available then the pharmacy would have sent the medication. LVN K said if refills were unavailable then the charge nurse was supposed to notify her because she was an agent of the doctor. LVN K said she then would call the prescription into the pharmacy. LVN K said she did not work on 11/28/2024 and did not believe the pharmacy was open on 11/27/2024. LVN K said she worked on 11/29/2024 but did not remember being notified Resident #11 was out of medication. LVN K said the nurses should have been able to get the alprazolam out of the e-kit if Resident #11 was out. LVN K said she would have had to call and authorize the prescription as an agent of the doctor. LVN K said then the charge nurses would have been able to call the pharmacy to obtain a code to remove controlled medication out of the e-kit. LVN K stated residents who did not receive antianxiety medication could have caused withdrawal symptoms or a panic attack. LVN K said signs of a panic attack were breathing heavy, and increased anxiety. During an attempted phone interview to gather additional evidence on 12/03/24 at 8:32 AM, LVN L did not answer the phone. A brief message was left with a call back number. No return call received upon exit of the facility. During an interview on 12/05/2024 beginning at 10:39 AM, the Pharmacy Technician said a nurse from the facility called in Resident #11's alprazolam on 11/29/2024. The Pharmacy Technician stated there was no call in to the pharmacy regarding Resident #11's alprazolam before that date. The Pharmacy Technician said it was called in after the first delivery cut off time, so the medication was delivered on the midnight run. The Pharmacy Technician said the medication was delivered on 11/30/2024 at 3:55 AM. The Pharmacy Technician said they were open all the time and was never closed, even during the holidays. The Pharmacy Technician said the facility would have been responsible for calling in the medication because they had no automatic system for refills. During an interview on 12/05/2024 beginning at 11:19 AM, PA M stated the psychiatric doctor typically was responsible for reordering psychotropic medication in residents who had a psychiatric diagnosis, such as anxiety. PA M stated if the facility was unable to get a response from the psychiatric doctor, then the facility could have notified him, and he would have sent in a 14 day order to the pharmacy. PA M stated he expected the facility staff to ensure controlled antianxiety medication was available to administer to the residents. PA M stated he was not notified Resident #11 was out of alprazolam during the last week (11/25/24 - 11/30/24). PA M stated Resident #11 had a true diagnosis of anxiety and histrionic behaviors. PA M stated Resident #11 was already anxious and going without her medication could have caused her to become more anxious. PA M stated it was important to ensure antianxiety medications were administered to keep the residents stable. During an interview on 12/05/2024 beginning at 12:32 PM, the DON said the charge nurse was responsible for monitoring to ensure medications were re-ordered and available at the facility. The DON stated the medication aide should have notified the charge nurse if controlled medications were running low. The DON said the charge nurse would have called the pharmacy to determine if refills were available. The DON said if refills were unavailable then the charge nurse should have notified the agent of the doctor at the facility. The DON stated the nursing management was responsible for monitoring the charge nurses to ensure medication was available. The DON stated she was notified on 11/30/2024 that Resident #11 was out of her medication when the alprazolam arrived at the facility. The DON stated the charge nurses should have gotten the medication out of the e-kit until the medication arrived. The DON said it was important to ensure Resident #11 received her antianxiety medication to keep her at a therapeutic level. The DON said if Resident #11 did not receive her medication it could have caused anxiety. During an interview on 12/09/24 beginning at 1:11 PM, the Administrator said he expected the nursing staff to administer medication as ordered and prescribed by the doctor. The Administrator stated a nurse was notified Resident #11 was out of medication and that nurse did not get the medication out of the e-kit. The Administrator stated he was unable to explain that and Resident #11's alprazolam should have been administered out of the e-kit. The Administrator stated if Resident #11 was on the medication long-term then they have a system in place for ensuring residents did not go without medication. The Administrator stated the medication aide should have notified the charge nurse when there were 8 or 9 pills left, so the charge nurse could have gotten a new order or refill. The Administrator stated nursing management was responsible for monitoring to ensure medication was available at the facility and the nursing staff was following the system for re-ordering medication. The Administrator stated it was important to ensure Resident #11 received her antianxiety medication so it did not increase her anxiety or behaviors. 33249 2. Record review of a face sheet dated 12/04/2024 indicated Resident #50 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia (memory loss), and malignant neoplasm of the female breast (breast cancer). Record review of the comprehensive care plan dated 6/28/2024 failed to indicate Resident #50 was receiving hormonal treatment for her diagnosis of breast cancer. Record review of the Quarterly MDS dated [DATE] indicated Resident #50's BIMS score was 3 indicating severe cognitive impairment, she was usually able to understand and was usually understood. Section I-Active Diagnoses failed to indicate the diagnosis of malignant neoplasm of the female breast as an active diagnosis. Record review of the physician's orders dated 12/04/2024 indicated Resident #50 was ordered Letrozole 2.5 milligram tablet give one tablet daily for breast cancer on 6/18/2024. Record review of the electronic administration record dated December 2024 indicated on 12/03/2024 Resident #50 had a missed dose of Letrozole 2.5 milligrams. During an observation and interview on 12/03/2024 at 8:33 a.m., RN A attempted to prepare Resident #50's ordered Letrozole 2.5 milligrams for administration but there were none available for administration. RN A placed an order for the medication using his computer. RN A said he would notify the physician of the missed dose of medication. RN A said he was unsure why the medication was unavailable. RN A said the nursing staff were responsible for ensuring medications were available for administration. 3. Record review of a face sheet dated 12/03/2024 indicated Resident #49 was a [AGE] year-old female who admitted on [DATE] with the diagnosis of a healing fracture and dementia (memory loss disease). Record review of an Admission MDS dated [DATE] indicated Resident #49 was understood and understood others. The MDS indicated Resident #49's BIMS score was a 6 indicating severe cognitive impairment. Section I-Active Diagnoses of the MDS indicated Resident #49 had a diagnosis of fractures or other multiple traumas. The MDS also indicated in Section I8000 Additional active diagnoses indicated pain to the left hip. Section J-Health Conditions in the section J0100 indicated Resident #49 received as needed pain medications. Record review of the comprehensive care plan dated 10/08/2024 indicated Resident #49 received pain medication for a right hip fracture. The goal of the care plan was Resident #49 would be free of any discomfort or adverse side effects from pain medications. The care plan interventions included to administer analgesic medications as ordered by the physician. Record review of the consolidated physician's orders dated 12/03/2024 indicated Resident #49 was ordered Tramadol 50 milligrams one tablet three times daily. Record review of the electronic medication administration record dated December 2024 indicated Resident #49 was administered Tramadol 50 milligrams on 12/03/2024 at 9:00 a.m. and 3:00 p.m. Record review of the undated narcotic administration record on 12/03/2024 at 4:30 p.m., Resident #49's Tramadol 50 milligrams was not signed out for the doses administered at 9:00 a.m. and 3:00 p.m. Record review of a Medication Administration Audit Report dated 12/03/2024 indicated Resident #49 was administered Tramadol 50 milligrams at 9:58 a.m. by RN A, and at 3:56 p.m. by MA B. The Medication Administration Audit Report failed to indicate a Tramadol 50 milligrams was administered at 4:30 p.m. on 12/03/2024 when MA B had the Tramadol 50 milligrams prepared and attempting administration when the surveyor intervened. The Medication Administration Audit Report indicated MA B administered the 9:00 p.m. dose of Tramadol 50 milligrams at 8:16 p.m. During an observation and interview on 12/03/2024 at 4:30 p.m., MA B was walking away from the 300-hall medication cart with a medication cup with one tablet in the cup. MA B said was he was administering Resident #49's Tramadol at this time. MA B provided the narcotic administration sheet for the surveyor to review. The narcotic administration record indicated there had not been any entries of the administration of the Tramadol for 12/03/2024. MA B was then asked to reconcile the narcotic Tramadol with the surveyor. Resident #49's narcotic administration record indicated there was 57 medications on hand. Resident #49's medication card of Tramadol 50 milligrams RX 5505760.00 filled on 11/21/2024 had 54 tablets. Resident #49's narcotic administration record indicated there should be 57 tablets available for administration. MA B said he had not reconciled the narcotics with RN A prior to taking over the medication cart. MA B was unable to explain the risks involved in not accurately reconciling the narcotics. During an interview on 12/03/2024 at 6:00 p.m., RN A said he had administered Resident #49's Tramadol for the 9:00 a.m., and 3:00 p.m. doses but failed to sign out the narcotic sheet. RN A said he was distracted and failed to sign out the administered medication on the narcotic sign out sheet. RN A said the narcotic sign out sheet should be signed when administering the medication. RN A said the risks were medication errors with readministering medications, and drug diversions (missing medications). RN A said the narcotic counts were to be reconciled at the start of a shift and at the end of shift, and/or when changing of nursing staff. Record review of a Medication Administration Observation Report dated 7/19/2024 indicated MA B was observed by the pharmacist in the techniques including correct medication verified by visual check of the medication, label, and MAR (omission, unordered medication, wrong dose, route, dosage form, drug, and time). Record review of a Competency Assessment Administering Oral Medications dated 9/12/2024 indicated RN A was checked off on medication administration by the ADON. The check off included 9b. For Narcotics check the narcotic record for the previous drug count and compare with supply on hand. Report any discrepancies to the nurse supervisor. During an interview on 12/05/2024 at 11:30 a.m., the DON said she expected the medications to be signed out as administered. The DON said the importance of signing out as administered was to prevent re-administration and accurate record keeping. The DON said she expected the nursing staff to reconcile the narcotics each shift prior to accepting the cart and at the end of the shift prior to the next nurse assuming the cart. The DON said spot checks and check offs were used to ensure compliance. During an interview on 12/05/2024 at 11:48 a.m., LVN E said he expected the MAs to sign out the medications as they were administered to ensure medications were not re-administered. LVN E said nursing was responsible for re-ordering medications timely. During an interview on 12/05/2024 at 12:46 p.m., the Administrator said medication counting was a critical part of shift change. The Administrator said medications should be documented as giving as they were administered to ensure nursing was aware the medication was administered. The Administrator said signing out of narcotics was a way to account for the use of the narcotics. The Administrator said he expected the nurse to monitor the MAs, the ADON and DON were responsible for oversight ultimately. 4)Record review of a face sheet dated 12/05/2024 indicated Resident #5 was a [AGE] year-old male who admitted on [DATE] and 3/09/2024 with the diagnoses of cognitive impairment, and low back pain. Record review of the comprehensive care plan dated 4/05/2024 indicated Resident #5 had chronic and acute pain related to diabetic disease and chronic low back pain. The goal of Resident #5's care plan was he would not have an interruption of his normal activities due to pain. The interventions included monitor and document causes of each pain episode, monitor/record/report to the nurse resident complaints of pain or request of pain treatment, notify the physician if interventions were unsuccessful or current complain was a significant change from the resident's past experience of pain. Record review of a Quarterly MDS dated [DATE] indicated Resident #5 was understood and understood others. The MDS indicated Resident #5's BIMS score was 9 indicating moderate cognitive impairment. The MDS in Section J-Health Conditions indicated Resident #5 received routinely scheduled pain medications and had not received as needed pain medications. Record review of the consolidated physician's orders dated 12/05/2024 indicated Resident #5 was ordered Norco Oral Tablet 10/325 milligram (hydrocodone-acetaminophen) give 1 tablet by mouth 4 times daily for pain on 4/05/2024. Record review of the Medication Administration Record dated December 2024 indicated on 12/04/2024 Resident #5 was scheduled to receive Norco 10/325 milligrams one tablet at 1:00 a.m., 7:00 a.m., 1:00 p.m., and 7:00 p.m. Record review of the undated Individual Narcotic Count Sheet indicated Resident #5's Rx N7443372 Norco (hydrocodone) 10/325 milligrams was signed out on 12/04/2024 at 2:00 a.m., 8:00 a.m., 2:00 p.m., and 8:00 p.m. dose indicated was pulled for dosing by MA B but wasted by the DON. Record review of the Medication Administration Audit Report dated 12/02/2024 - 12/04/2024 indicated Resident #5 last administration of Norco 10/325 milligrams at 12:34 p.m. for the scheduled 1:00 p.m. by MA C. During an observation and interview on 12/04/2024 at 3:44 p.m., MA B was standing at the medication cart. MA B was asked to allow the surveyor to review the medication cart for compliance with opened and dated medications, and cleanliness. MA B opened the top drawer of the medication cart and there were 3 medication cups with prepared medications for administration. MA B grabbed the cups and attempted to place them in his jacket pocket. Upon request MA B removed the medications from his pocket and attempted to add applesauce to the medication cup MA B indicated was for Resident #5. MA B indicated Resident #5 was crying in pain and he was administering the 7:00 p.m. scheduled Norco 10/325 milligram at this time. MA B attempted several times to walk inside Resident #5's room to administer the medication but was stopped each time by the surveyor to clarify the administration. MA B said RN D had advised him to administer this medication. RN D who was standing a few feet away was summoned to the medication cart. RN D said he had in fact had not been consulted concerning Resident #5 crying in pain or the need to administer Norco 10/325 milligram at this time. RN D summoned the DON as requested . The DON and Corporate Clinical Nurse arrived at the medication cart. The DON questioned MA B concerning his preparation and attempt of administration of Resident #5's 7:00 p.m. medications at 3:44 p.m. MA B attempted to inform the DON of how Resident #5 was crying in pain and needed the medication early. The DON was noted to inform MA B this was out of his scope of practice and that he was not able to administer any medications without the physician's order. The DON advised MA B to waste the Norco 10/325 milligram medication at this time with her approval. The DON was informed the surveyor intervened in the administration due to the fact Resident #5's narcotic sheet indicated he had received his Norco 10/325 milligram at 2:00 p.m. just 1 hour and 44 minutes earlier. During an interview on 12/04/2024 at 4:32 p.m., the DON indicated Resident #5 was assessed and he denied being in pain and was sitting up in his wheelchair in his room. The DON said Resident #5 probably would not have suffered any adverse effects from the early administration of the Norco 10/325 milligrams, but another resident could suffer adverse effects. The DON said she had validated with MA B no other residents had received medications early off their scheduled times. Record review of a Medication Administration Observation Report dated 7/19/2024 indicated MA B was observed by the pharmacist in the techniques including correct medication verified by visual check of the medication, label, and MAR (omission, unordered medication, wrong dose, route, dosage form, drug, and time). During an interview on 12/05/2024 at 11:39 a.m., the DON said she expected the MAs and nurses to follow the rights of medication administration including right time. The DON said administering pain medications too closely together could adversely affect some residents. The DON said she monitors the medication audit report to monitor for missed doses. The DON said the pharmacist also monitors the nursing staff with medication compliance. The DON said the nurses were responsible for reordering medications timely to ensure the medications were available for administration. The DON said missed medications could affect the residents adverse by not having optimal levels and effectiveness. During an interview on 12/05/2024 at 11:55 a.m., RN E said MAs were unable to assess residents for pain and decide what the course of action should be. RN E said the nurse should assess for pain, evaluate when the last administration of pain medications was provided, evaluate if an as needed dose of medication was required, and notify the physician for further guidance. RN E said nurses and MAs were responsible for reordering timely to ensure no medications were missed due to unavailability. RN E said the physician should be notified and all attempts made to ensure the medication was available for administration. During an interview on 12/05/2024 at 1:00 p.m., the Administrator said the nursing staff should know when the medication was low and order prior to exhausting what was on hand. The Administrator said the nurses have access to the emergency kit and the pharmacy could make a stat (three hour turn around) delivery. The Administrator said MA B made a decision he had never witnessed before. The Administrator said MA B failed to follow the facility's process for medication administration. The Administrator said nursing management was responsible for ensuring monitoring of medication management and administration of staff competencies. Record review of an Adverse Consequences and Medication Error policy dated April 2014 indicated, the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions and side effects 6. Examples of medication errors included: b. Unauthorized drug is administered without a physician's order g. Wrong time Record review of a Documentation of Medication Administration policy dated April 2007 indicated, the facility shall maintain a medication administration record to document all medications administered. 1. A nurse or Certified Medication Aide shall document all medication administer to each resident on the resident's medication administration record (MAR). Record review of a Controlled Substance policy dated December 2012 indicated, the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances. 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nursing going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. Record review of Medication Orders and Receipt Record policy, dated April 2007, reflected Medication should be ordered in advance, based on the dispensing pharmacy's required lead time. Record review of the Pharmacy Services - Role of the Provider Pharmacy, dated April 2010, reflected the provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including (but not limited to), the following: .establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medications and prescriptions .provide and maintain the facilities emergency medication supply .deliver medications to the facility . Record review of a Documentation of Medication Administration policy dated April 2007 indicated, the facility shall maintain a medication administration record to document all medications administered. 1. A nurse or Certified Medication Aide shall document all medication administer to each resident on the resident's medication administration record (MAR). Record review of a Controlled Substance policy dated December 2012 indicated, the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances. 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nursing going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings.

Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #49) residents reviewed for care plan revisions. The facility failed to revise Resident #49's care plan to remove her wound care when she no longer had a wound. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression(a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly MDS assessment dated [DATE], indicated Resident #49 understood and was understood by others. The MDS assessment indicated Resident #49 had a BIMS score of 10 indicating she was moderately cognitively impaired. The MDS indicated she required assistance with ADLs and set up for meals. The MDS did not indicate any wounds. Record review of Resident #49's comprehensive care plan revised on 04/03/24, indicated Resident #49 had a Stage 3 pressure ulcer on the right hip related to decreased mobility. The care plan interventions were for staff to provide wound care as ordered. Record review of Resident #49's order summary report dated 12/04/24, indicated Resident #49 had no wound orders. Record review of Resident #49 wound care note dated 04/24/24 indicated her wound had healed. During an interview on 12/05/24 at 11:14 a.m., MDS Coordinator N said she was responsible for the care plans for the long-term residents. She said the care plan was done so the staff would know how to care for the resident. She said she was made aware of the residents' changes in the morning meeting and at times the floor staff would communicate to her about changes. She said anytime the residents had a change in their care, she should revise the care plan. She said Resident #49's wounds had healed, and the care plan should have been revised. She said care plans were done to reflect the resident's care. During an interview on 12/05/24 at 11:49 a.m., the DON said she expected the care plans to be accurate. She said the MDS Coordinator was responsible for ensuring the care plans were kept current with the resident's care. She said during the morning meetings they discussed any changes with the resident's care, she said they also had weekly and quarterly meetings where the care plan should have been updated. She said Resident #49 did not have any current wounds. She said it was important to have the most updated care plan so that staff would know what care they needed to provide. During an interview on 12/04/24 at 12:46 p.m., the Administrator said the MDS Coordinator was responsible for the care plans. He said the DON was the overseer of the care plans. He said if care plans were not done residents might receive something they do not need or not receive something they do need. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated, Policy statements 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. Policy interpretation and implementation #2 The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment #13 Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. #14 The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident's condition, b. when the desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay and, d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 18 Residents (Resident #37) reviewed for accidents and hazards. The facility failed to ensure Resident #37 had on her wander guard bracelet on 12/2/24 and 12/3/24. This failure could place residents at risk of elopement, injury, or harm. Findings included: 1.Record review of Resident #37's face sheet, dated 12/04/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), Schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact with others), and depression (sadness). Record review of Resident #37's quarterly MDS assessment, dated 11/21/24, indicated Resident #37 understood and was understood by others. Resident #37's BIMS score was a 10 indicating her cognition was moderately impaired. The MDS indicated Resident #37 required limited assistance with her ADLs including transfers and bed mobility. The MDS indicated she had an elopement/wander alarm. Record review of Resident #37's comprehensive care plan dated 09/30/24 indicated, she was at risk for elopement/wandering related to impaired safety awareness. The interventions were for staff to monitor the wander guard to the left lower leg and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Also, remind the resident not to leave the facility without assistance. Record review of Resident 37's Physician order dated 09/16/24 indicated, she had a wander guard to the Left lower leg related to exit-seeking behaviors. Check placement every shift. Record review of Resident #37's Elopement Risk Evaluation dated 09/16/24 indicated she was at risk of elopement. During an observation on 12/02/24 at 11:35 a.m., Resident #37 was in bed with no wander guard bracelet on her left lower leg. During an interview on 12/04/24 at 5:00 p.m., Resident #37 said she did have on her wander guard, but it had been removed a long time ago (unknown date). During an observation and interview on 12/04/24 at 5:18 p.m., Resident #37 was lying in her bed and no wander guard was on her leg. CNA R verified by looking at Resident #37's leg and said she did not have a wander guard bracelet on. During an interview on 12/05/24 at 11:49 a.m., the DON said Resident #37 was supposed to have her wander guard on and the nurses should check for placement each shift. She said Resident #37 had removed her wander guard before but was not sure why Resident #37's wander guard was not in place. She said all staff was responsible for ensuring the residents who had orders for wander guards, had the wander guards on. She said if Resident #37 did not have on her wander guard she was at risk for elopement. During an interview on 12/05/24 at 12:46 p.m., the Administrator said if Resident #37 had an order for a wander guard, then she should have had on her wander guard. He said wander guards were used for residents at risk of wandering. He said all staff were responsible for ensuring the wander guard was in place. Record review of facility policy titled, Wandering and Elopement, dated November 15, 2023, indicated, Policy statement: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Policy interpretation and implementation: identifying residents at risk 1. on admission, readmission, quarterly doing observation period of the MDSs, annual significant changes, and as needed. The nurse will screen each resident for elopement risk using the elopement risk evaluation or equivalent form. After reviewing this information, the nursing staff will determine if the resident is at risk of wandering or elopement.

Based on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #25) reviewed for (DRR) Drug Regimen Review. The facility failed to implement the pharmacy recommendations for Resident #25's medications that contained acetaminophen. This failure could place residents at risk for adverse side effects and not receiving medications at the most effective dosage. The findings included: Record review of the order summary report, dated 12/04/2024, reflected Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate) and chronic pain. Record review of the quarterly MDS assessment, dated 11/21/2024, reflected Resident #25 had no speech and was rarely/never understood by others. The MDS reflected Resident #25 was rarely/never able to understand others. The MDS reflected Resident #25 had poor long-term and short-term memory problems. The MDS reflected Resident #25 was unable to recall the current season, location of her own room, staff names and faces, or that she was in a nursing home. The MDS reflected Resident #25 had severely impaired decision making skills. The MDS reflected Resident #25 had an active diagnosis of chronic pain. The MDS reflected Resident #25 had no indicators of pain or possible during the last five days of the look-back period. Record review of the comprehensive care plan, revised 11/08/2024, reflected Resident #25 received pain medication therapy. The interventions included administer medication as ordered by the physician. Record review of the Director of Nursing Report from the pharmacy consultant, dated 08/28/2024, reflected Resident #25 had a pharmacy recommendation that stated Please note this resident has orders for routine and/or prn medications that contain acetaminophen. The FDA believes that limiting the amount of acetaminophen per tablet, capsule, or other dosage unit in prescription products will reduce the risk of severe liver injury from acetaminophen overdosing, an adverse event that can lead to liver failure, liver transplant, and death. Due to the high concern of hepatic injury, the makes or OTC Extra Strength Tylenol (acetaminophen) have voluntarily decided to change the directions on their label to include a revised maximum daily dosage of 3,000 mg (3 gm). Suggest adding to all orders that contain acetaminophen to not exceed 3,000 mg (3 gm) per day. Record review of the Director of Nursing Report from the pharmacy consultant, dated 09/26/2024, reflected Resident #25 had a pharmacy recommendation that stated Please note this resident has orders for routine and/or prn medications that contain acetaminophen. The FDA believes that limiting the amount of acetaminophen per tablet, capsule, or other dosage unit in prescription products will reduce the risk of severe liver injury from acetaminophen overdosing, an adverse event that can lead to liver failure, liver transplant, and death. Due to the high concern of hepatic injury, the makes or OTC Extra Strength Tylenol (acetaminophen) have voluntarily decided to change the directions on their label to include a revised maximum daily dosage of 3,000 mg (3 gm). Suggest adding to all orders that contain acetaminophen to not exceed 3,000 mg (3 gm) per day. Record review of the order audit report, dated 12/04/2024, reflected Resident #25 had an order for acetaminophen - give 500 mg by mouth every 6 hours as needed for pain or fever. The order did not indicate to not exceed 3,000 mg (3 gm) per day. Record review of the order audit report, dated 12/04/2024, reflected Resident #25 had an order for Norco (Hydrocodone-Acetaminophen) 5-325 mg - Give 1 tablet by mouth every 6 hours as needed for pain. The order did not incident to not exceed 3,000 mg (3 gm) per day. During an interview on 12/05/2024 beginning at 10:54 AM, the Pharmacy Consultant stated when she made recommendation, she expected the facility to follow up and address the recommendations. The Pharmacy Consultant stated she expected do not exceed 3,000 mg (3gm) per day on at least one of the orders that contained acetaminophen. The Pharmacy consultant stated it was important to ensure do not exceed 3,000 mg (3 gm) per day was on the orders because it was the manufactures guidelines. The Pharmacy Consultant stated administering acetaminophen in the elderly placed them at risk for liver toxicity if they were to exceed 3,000 mg. The Pharmacy Consultant said it was important to have the information on the orders so the nurses were aware and could have calculated the amount of acetaminophen Resident #25 was getting. During an interview on 12/05/2024 beginning at 12:32 PM, the DON said when the pharmacy recommendations were received, she printed them out. The DON said her and the ADON went through the recommendations and updated the orders. The DON stated she missed Resident #25's recommendation for the acetaminophen. The DON said it was important to ensure pharmacy recommendations were implemented to ensure residents were getting the best care they could. During an interview on 12/05/2024 beginning at 1:11 PM, the Administrator stated he expected the pharmacy recommendations to be addressed and implemented. The Administrator stated nursing leadership was responsible for ensuring pharmacy recommendations were implemented. The Administrator stated failing to implement pharmacy recommendations could have placed residents at risk for side effects from medication or discomfort. Record review of the Pharmacy Services - Role of the Consultant Pharmacist policy, revised April 2007, reflected the consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility including: .helping identify and evaluate medication-related issues .appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities . The policy did not address implementing pharmacy recommendations.

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 medication carts (Hall 300 nurse medication cart and 300 hall medication cart) of 6 medication carts reviewed for medication storage. The facility failed to ensure MA B secured a controlled narcotic medication when he left a Tramadol inside a medication cup sitting on the 300-hall medication cart when he walked to the nurse's station. The facility failed to ensure RN F secured the 300-hall nurse cart when she entered the room, standing behind the privacy curtain to obtain a blood pressure, then again when she went behind the privacy curtain to obtain the over-the-bed table to prepare the supplies, then lastly when she closed the door and stepped behind the privacy curtain to administer the gastrostomy tube medications. Theseis failures could place residents at risk of ingesting medications not prescribed, and access to sharps (needles and lancets). Findings included: During an observation and interview on 12/03/2024 at 4:30 p.m., MA B had a medication cup in his hand, and a cup of water. MA B was asked about the administration of the medication in the cup. MA B said he needed to retrieve his computer from the nurse's station at the end of the hall 300. MA B placed the medication cup with a Tramadol 50 milligrams on top of the 300-hall medication cart while he went to obtain his computer from the nurse's station. MA B was out of the surveyor's line of site when he left the medication. MA B refused to answer why securing the medication was important. During an observation and interview on 12/03/2024 at 7:00 p.m., RN F took 300-hall cart to the resident's room . RN F opened the cart, obtained a blood pressure cuff, then walked into the room to assess the residents blood pressure. RN F then returned to the unlocked cart, then re-entered the room to obtain the over-the-bed table. After RN F prepared the medications for administration, she entered the room, shut the door, and went around the privacy curtain to administer the medications. RN F said she should have locked her medication cart each time. RN F said any resident can open the cart and obtain medications that were not prescribed to them. During an interview on 12/05/2024 at 11:42 a.m., the DON said she expected the medications and medication carts to be secured when not within site or easy reach. The DON said a resident could get into the cart, obtain medications, and pilfer through the cart. The DON said nurse management monitored with spot checks looking for unlocked carts and unsecured medications. The DON said nurses, medication aides, and nurse management were responsible for ensuring the medication carts remain locked and medications remain secured. During an interview on 12/05/2024 at 1:09 p.m., the Administrator said he expected the medications and medication carts to be always secured. The Administrator said management rounds were made several times during the day to check for compliance. The Administrator said drug diversions and residents could suffer adverse effects from obtaining medications from an unsecured medication cart. Record review of a Storage of Medications policy dated April 2019 indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). 9. Unlocked medication carts are not left unattended.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 18 residents (Resident # 14) reviewed for MDS assessment accuracy. The facility failed to code Resident #14's hospice accurately. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #14's face sheet, dated 12/04/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia(forgetfulness), seizures, anxiety (uneasiness or fear), and high blood pressure. Record review of Resident #14's physician orders dated 07/27/24 indicated an order for {name} hospice. Record review of Resident #14's quarterly MDS assessment, dated 11/08/24, indicated Resident #14 was not on hospice service. Record review of Resident #14's care plan dated 10/29/24 indicated Resident #14 had a terminal prognosis and was on hospice service. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. During an interview on 12/04/24 at 1:42 p.m., the MDS Coordinator N said she was responsible for the completion of the MDS assessments. She looked at section O on Resident # 14 MDS assessment and said she did not code hospice. She said Resident #14 was on hospice services. She said it was important to code the MDS assessment correctly because it reflected their care and reimbursement. During an interview on 12/05/24 at 11:49 a.m. the DON said the MDS Coordinator was responsible for completing the MDS assessments. The DON stated she did not know why the MDS indicated Resident # 14 was not on hospice. The DON stated it was important for the MDS assessments to be accurately coded to make sure they provided the residents with the care they needed. During an interview on 12/05/24 at 12:26 p.m. the Administrator said the MDS Coordinator was responsible for completing the MDS assessments. He said the DON was the overseer. The Administrator said he expected the MDS assessment, for any resident, to be completed thoroughly and correctly based on the resident assessment. During an interview on 12/05/24 at 12:46 p.m., the Regional Nurse Consultant indicated they do not have a policy for MDS coding. She said they follow the CMS RAI manual. Record review for the RAI manual on https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual: indicated on Section 00110 to code if a resident was on hospice.