Every finding on record at Bryan County HLTH & Rehab CTR

Based on observation, staff interviews, and review of the facility's policy titled Preparation of Pureed Foods for Residents with Dysphagia, the facility failed to ensure that pureed foods were prepared according to standardized recipes and professional food service standards for residents (R) requiring texture modified diets. This deficient practice had the potential to affect nine residents receiving pureed diets.Findings Include:Review of the undated policy titled Preparation of Pureed' foods for the Residents with Dysphagia, revealed under the Moist and Consistency section, to add appropriate liquids to achieve proper consistency: broth, milk, gravy or approved thickened liquids. It was revealed under the Nutritional Adequacy section to ensure meals meet residents' nutritional needs. Fortify foods when needed (e.g., adding protein powder, butter, or supplements).Observation and interview on 03/31/2026 at 10:49 AM revealed that Dietary Aide (DA) HH did not use a recipe while pureeing carrots and chicken dumplings. Carrots and water were used to prepare the pureed carrots. A can of chicken and dumplings, cream of chicken soup, and water were used to prepare the pureed chicken and dumplings. Measuring tools were not used to determine the amount of ingredients added. DA HH stated that she had been preparing pureed meals for a long time and knew how to prepare them without a recipe. She confirmed that she does not use a recipe when completing the puree process.Interview on 03/31/2026 at 11:32 AM with the Certified Dietary Manager (CDM) confirmed that the DA did not use a recipe. The CDM stated that she realized the process was incorrect once it had already begun but explained that seasoned workers have been doing the work for a long time and tend not to use a recipe. She stated that chicken and dumplings were added to the menu for that evening's dinner and confirmed that the facility does not have a recipe for that dish.Interview on 04/01/2026 at 12:43 PM with the Director of Nursing (DON) revealed that she was unaware that dietary staff were not using recipes. The DON stated that her expectation is that all dietary staff use recipes when preparing all meals, including pureed meals, to ensure that residents receive proper nutritional balance.

Based on observation, staff interviews, record review, and review of the facility's policy titled Food Storage, the facility failed to ensure that all foods were properly labeled, dated, and discarded, and failed to ensure the cleanliness of kitchen equipment used in the preparation of food for residents. Failure to follow this policy resulted in improper food storage and unsanitary food preparation practices. This deficient practice had the potential to place 83 residents (R) who received an oral diet at risk of contracting a foodborne illness.Findings include:A review of the facility's undated policy titled Food Storage, documented under Food Service Employees, Stock is rotated so that older items are used first. Products are dated to assure First In- First Out procedures are followed. Foods are inspected regularly for damage due to spoilage. Dented, bulging, leaking cans will be discarded, or returned to vendors for appropriate credit. The purpose is to prevent the transmission of disease carrying organisms.Observation tour of the kitchen on 03/30/2026, beginning at 10:15 AM, conducted with the Certified Dietary Manager (CDM), revealed the following concerns, all of which were identified and confirmed by the CDM:Three loaves of raisin bread without an expiration dateOne pack of hot dog buns without an expiration dateRefrigerator contained five one pound containers of Roasted Beef Base with an expiration date of May 2025Refrigerator contained one one pound container of Roasted Beef Base with an expiration date of November 2025Refrigerator contained one one pound container of Roasted Beef Base with an expiration date of April 2025Refrigerator contained one five pound bag of Assorted Grated Parmesan Cheese with an open date of 01/25/2026, but no use by dateRefrigerator contained one metal container of French Vanilla Alamera with a use by date of 03/06/2026The can opener contained a greasy, black substanceInterview on 03/30/2026 at 10:46 AM with the CDM confirmed the identified concerns. She stated that it is her expectation that dietary staff require re education on proper labeling, dating, and disposal of out of date food items.Interview on 03/30/2026 at 12:43 PM with the Director of Nursing (DON) revealed that it is the expectation of the facility that dietary staff properly label, date, and dispose of out of date food items.

Based on observations, staff interviews, and the facility policy, Outside Dumpster Policy the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. Findings include:A review of the facility's undated policy titled Outside Dumpster Policy revealed several key requirements. Under General Waste Disposal, dumpster lids must remain closed at all times after use, and trash bags must not be left on the ground or outside the dumpster. In Approved Waste Only, only designated general trash may be disposed of in outside dumpsters. Under Safety Guidelines, staff must report damaged dumpsters or unsafe conditions immediately to maintenance, and the dumpster area must be kept free of debris to prevent slips, trips, and falls.Observation and interview on 03/30/2026 at 10:58 AM of the trash dumpster area, accompanied by the Dietary Manager (DM), revealed that numerous wooden pallets were present behind the dumpsters. The top lids of two of the three dumpsters were open, and the side door of one dumpster was also open. The DM confirmed the presence of the wooden pallets and stated that it was the responsibility of the maintenance department to remove and discard them. She also acknowledged that the side door and top lids of the dumpsters were left open at the time of observation. The DM stated that it was the responsibility of the dietary staff to keep all dumpster doors and lids closed and that her expectation was for all staff to ensure the dumpsters remained closed.A follow up observation on 03/31/2026 at 9:02 AM revealed that the side door of the trash dumpster remained open and the wooden pallets were still present behind the dumpsters. A subsequent observation on 04/01/2026 at 7:56 AM revealed that the wooden pallets continued to remain behind the dumpsters.Interview on 04/01/2026 at 12:43 PM with the Director of Nursing (DON) revealed that she was unaware of the wooden pallets behind the dumpsters and was also unaware that the dumpster doors or lids had been left open. The DON stated that it was her expectation that both dietary and maintenance staff be re educated on the facility's Outside Dumpster Policy.

Based on observations, staff and resident interviews, record review, and review of the policy titled Resident Dignity & Safe Feeding Policy, the facility failed to maintain dignity for four of 45 sampled residents (R7, R27, R67, and R83). This failure placed the residents at risk for a reduced quality of life in an environment meant to support their well being.Findings Include:Review of the facility's policy titled, Resident Dignity & Safe Feeding Policy, revised 7/23/2025 revealed that Prohibited Practices included Do not feed while standing, rush feeding, feed multiple residents at once, or ignore swallowing difficulty.1.Review of the Quarterly Minimum Data Set (MDS) for R7, dated 02/01/2026, revealed that Section C (Cognitive Patterns) documented that R7 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R7 was dependent on eating and with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, Alzheimer's disease, feeding difficulties, schizoaffective disorder, and dysphagia.Review of the care plan for R7, dated 02/09/2026, revealed that R7 was at risk for decreased quality of life related to inability to perform activities of daily living (ADL) skills independently due to impaired mobility, cognitive deficit, weakness, and poor endurance. Interventions included setting up the meal tray, ensuring the correct texture and diet were served, and assisting with eating as needed. Staff were to provide oral care as needed. She required staff assistance with personal hygiene.Record review revealed that R7 had an order dated 03/07/2024 for a regular diet, mechanical soft texture, regular consistency, Mighty Shake, and chopped meat with meals.Observation on 03/31/2026 at 7:35 AM revealed that Social Service DD was standing to feed R7.Interview on 03/31/2026 at 7:48 AM with Social Service DD revealed that she routinely sits next to residents and talks with them.2.Review of the Quarterly Minimum Data Set (MDS) for R27, dated 02/20/2026, revealed that Section C (Cognitive Patterns) documented that R27 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R27 was dependent on eating and with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, acute combined systolic and diastolic heart failure, aphasia, dysphagia, and feeding difficulties.Review of the care plan for R27, dated 02/24/2026, revealed that R27 was at risk for decreased quality of life related to inability to perform activities of daily living (ADL) skills independently due to impaired mobility, cognitive deficit, weakness, and poor endurance. Interventions included staff assistance with eating, setting up the meal tray, ensuring the correct texture and diet were served, assisting with eating as needed, and providing oral care as needed. She required staff assistance with personal hygiene.Record review revealed that R27 had an order dated 01/02/2024 for a regular diet, pureed texture, and regular consistency.Observation on 03/31/2026 at 7:38 AM revealed that Licensed Practical Nurse (LPN) BB was standing to feed R27.Interview on 03/31/2026 at 7:40 AM with LPN BB confirmed that she was standing to feed R27. She admitted that she should sit at eye level to feed the resident.3.Review of the Annual Minimum Data Set (MDS) for R67, dated 03/04/2026, revealed that Section C (Cognitive Patterns) documented that R67 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R67 was dependent on eating and with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, dementia, hypertension, feeding difficulties, and mood disorder.Review of the care plan for R67, dated 03/03/2026, revealed that R67 was at risk for decreased quality of life related to inability to perform activities of daily living (ADL) skills independently due to impaired mobility, cognitive deficit, weakness, diagnosis of dementia, and poor endurance. Interventions included setting up the meal tray, ensuring the correct texture and diet were served, and assisting with eating and oral care as needed. She required staff assistance with personal hygiene.Record review revealed that R67 had an order dated 10/26/2023 for a mechanical soft texture, regular consistency, fortified foods at every meal, with pureed meats.Observation on 03/31/2026 at 7:35 AM revealed that Certified Nursing Assistant (CNA) EE was standing to feed R67.Interview with CNA EE on 03/31/2026 at 7:42 AM confirmed that she was standing while feeding R67. She admitted that she was supposed to sit at eye level to feed R67.4.Review of the Annual Minimum Data Set (MDS) for R83, dated 02/24/2026, revealed that Section C (Cognitive Patterns) documented that R83 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R83 was dependent on eating and with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, Down Syndrome, epilepsy, protein C resistance, Moyamoya disease, and sleep apnea.Review of the care plan for R83, dated 02/24/2026, revealed that the resident had an activity of daily living (ADL) self care performance deficit.Record review revealed that R83 had an order dated 02/17/2025 for a regular diet, pureed texture, and regular consistency.Observation on 03/31/2026 at 7:35 AM revealed that LPN CC was standing while feeding R83 breakfast.Interview on 03/31/2026 at 7:45 AM with LPN CC confirmed that she was standing while feeding R83 breakfast. She stated that she can stand or sit, but most of the time she sits to feed residents. She explained that residents on the C Hall were different because they have dementia, so staff may sit or stand to assist with feeding.Interview on 04/01/2026 at 9:47 AM with LPN FF revealed that staff are to sit by the residents to assist with feeding.Interview on 04/01/2026 at 11:00 AM with the Assistant Director of Nursing (ADON) revealed that staff are to sit at eye level to feed residents.Interview on 04/01/2026 at 11:29 AM with the Director of Nursing (DON) revealed that staff are to sit next to residents at eye level.

Based on observations, staff and resident interviews, record review, and review of the policy titled, Self Administration of Medications at Bedside Policy, [NAME] County Health and Rehabilitation Center, the facility failed to ensure that one of 46 sampled residents, Resident R23, did not have access to self administered medications. This failure had the potential to place Resident R23 at risk for adverse consequences. Findings include:Record review of policy titled, Self- Administration of Medications at Bedside Policy [NAME] County Health and Rehabilitation Center revised 05/03/2025 documented I. Policy Statement -Residents who are capable of safely managing their own medications may be permitted to self-administer medication at the bedside in accordance with physician orders, facility assessment, and applicable state and federal regulations. IV. Eligibility Criteria: Residents are not eligible if they: Have cognitive impairment affecting safety. Have a history of medication misuse. Are at risk for harm to self or others. V. Assessment Process A. Initial Assessment: Completed by license nurse: Cognitive status. Physical ability (vision, dexterity) Understanding medications. B. Physician ordered required. Must include Approval for self-Administration and any limitations.Record review of resident R23's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 05 indicating severe cognitive impairment.Record review of the care plan dated 07/18/2025 with a target date of 04/13/2026 for R23 revealed she is at risk for impaired communication due to impaired cognition. R23 has impaired cognitive function/impaired thought processes with a diagnosis of dementia, severe with other behavioral disturbances, metabolic encephalopathy, and cognitive communication deficit.Record review R23 Physician Orders revealed there is no order for residents to have medications at her bedside to self-administer.Record review of the medical records for R23 there was no assessment done for medication self-administration.Observation on 03/30/2026 at 9:00 AM during the initial tour of the facility revealed R23 was observed with approximately eight different pills. R23 stated that she was taking them slowly because she did not feel well. She reported that the nurse had given her morning medication with some water and that she was taking it by herself at the bedside. She stated that she was not supposed to take medication without supervision and that she was unsure whether she had an order for self administration. The medications were removed by Licensed Practical Nurse (LPN) GG. The Assistant Director of Nursing (ADON) entered the resident's room with LPN GG, and both confirmed that the resident had a medication cup containing eight medications at her bedside and that she did not have an order for self administration and was not to take medications unsupervised.An interview on 04/01/2026 at 10:00 AM with ADON revealed that residents do not have orders to self administer medications. She confirmed that the medication in the cup was the resident's morning medication. The ADON stated that the resident should never have been left with medication at the bedside. In a further interview, the ADON stated, It is very important that the medication nurse watch residents take their medication because anything can happen; she can choke on medication.An interview on 04/01/2026 at 10:43 AM with the Administrator confirmed that R23 should never have been left with medication, stating this was a dangerous practice and that staff know better than that.A phone interview on 04/01/2026 at 11:09 AM with LPN GG admitted that she should have quickly secured the medication and locked it in the cart before checking on another resident. LPN GG stated that only residents who are assessed and have a physician's order for self administration may take medications independently, and that she is required to watch residents take their medications.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration - General Guidelines, the facility failed to administer a medication at the correct time for one of eight sampled resident(R) (R6), whose medication was ordered to be given on an empty stomach, and failed to crush and administer medications separately for one of eight sampled R (R60). These failures occurred among eight residents with gastrostomy tubes observed during medication administration. This deficient practice had the potential to place R6 and R60 at risk for medical complications and abnormal laboratory results.Findings Include:Review of the facility's policy titled, Medication Administration-General Guidelines, effective date 4/1/2016 under Procedures revealed, A. Preparation. 7. Tablet crushing/Capsule opening: Crushing tables may require a physician's order, per facility policy.d. Medications should be crushed and administered individually if administered via tube. B. Administration. 12.Medicaitons are administered withing 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes.1.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident R6 under Section I (Active Diagnoses) revealed diagnoses that included, but were not limited to, hypothyroidism, Alzheimer's disease, and atrial fibrillation.Review of the care plan dated 03/18/2026 revealed that the resident had a diagnosis of hypothyroidism and was at risk for complications related to the condition, such as increased fatigue and sluggishness, increased sensitivity to cold, hoarseness of voice, increased blood cholesterol, increased forgetfulness, depression, muscle aches, pain, stiffness, and swelling of joints. Interventions included administering medications as ordered and notifying medical providers of any adverse side effects.Review of the physician's order dated 07/10/2023 revealed that R6 was to receive levothyroxine sodium 50 micrograms orally once daily for hypothyroidism.Observation and interview on 03/31/2026 at 9:04 AM with Licensed Practical Nurse (LPN) BB confirmed that the resident had already eaten breakfast. LPN BB confirmed that the medication was scheduled for 9:00 AM and that the label on the medication package instructed administration in the morning before breakfast.Interview on 04/01/2026 at 10:34 AM with the Consultant Pharmacist revealed that levothyroxine is to be administered on an empty stomach and should be scheduled at 6:00 AM, prior to breakfast. He confirmed that the resident was scheduled to receive the medication at 9:00 AM, after breakfast.Interview on 04/01/2026 at 11:29 AM with the Director of Nursing (DON) revealed that medications such as levothyroxine are to be administered at 6:00 AM on an empty stomach before breakfast. She stated that breakfast is served between 7:30 AM and 8:00 AM. She confirmed that the resident was scheduled to receive the medication at 9:00 AM.2. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident R60 under Section I (Active Diagnoses) revealed diagnoses that included, but were not limited to, cerebral infarction, epilepsy, gastrostomy status, and dysphagia.Review of the care plan dated 02/24/2026 revealed a focus area indicating that R60 required tube feeding to meet nutritional and hydration needs due to dysphagia following cerebral infarction. Interventions included flushing the tube with 15 mL of water before and after medication and 15 mL with each medication. Review of the record revealed a consent dated 08/14/2025 to crush all medications.Review of physician orders dated 08/14/2025 revealed instructions to flush the tube with 15 mL of water before and after medications and 15 mL with each medication every shift.Observation on 03/31/2026 at 8:32 AM of LPN BB revealed that the nurse placed all medications into a crushing pouch and crushed them together. She prepared supplies on the bedside table, including an enteral feeding tube clog remover. LPN BB applied gloves but did not wear a gown. She obtained water from the bathroom. The residents' door and curtain were left open. She flushed the tube with 60 mL of water, then administered liquid anti seizure medications, followed by a 15 mL water flush. LPN BB mixed all crushed medications together in 45 mL of water. She attempted to administer the mixture but was unable to do so because the tube became clogged. She kneaded and squeezed the feeding tube and inserted the clog remover to clear the obstruction. After repeated attempts, she was able to flush the tube with 15 mL of water. She added more water to the crushed medication mixture and administered it, followed by a 15 mL flush. She then resumed enteral tube feeding.Interview on 03/31/2026 at 9:00 AM with LPN BB confirmed that she crushed all of R60's medications together and administered them together. She stated that she knew she was not supposed to crush or administer medications together but explained that there were a lot of medications. She admitted that the tube became clogged after administering the crushed medications together.Interview on 04/01/2026 at 10:34 AM with the Consultant Pharmacist confirmed that medications administered through a gastrostomy tube should be crushed separately and administered separately.Interview on 04/01/2026 at 11:29 AM with the DON on revealed that medications administered through a gastrostomy tube are to be crushed individually and administered separately with 5 mL of water between each medication, or according to the physician's order.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in the Facility, the facility failed to ensure that one of two medication rooms was free of expired medications. This deficient practice had the potential to place residents at risk of receiving expired medications.Findings Include: A review of the facility's policy titled Medication Storage in the Facility, effective 4/1/2026, documented under section Expiration Dating (Beyond-Use dating).a.Blister-pack cards and medication vials-12 months from the date of dispensing (where the manufacture's expiration date is longer than 12 months). C.Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose injectable vial, an ophthalmic medication,3. An item for which the manufacturer has specified as usable life after opening.D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.Observation and concurrent interview on 03/31/2026 at 2:25 PM with the Assistant Director of Nursing (ADON) in the medication room for Hallways A and B revealed the following expired or improperly dated items:One box of povidone iodine swab sticks expired 09/2025Five bottles of mineral oil enemas expired 01/2025One bottle of Prostate expired 02/12/2026One bottle of fiber laxative expired 02/2026A tuberculin vial stored in the medication room refrigerator without an open date or expiration dateThe ADON stated she was unsure when the vial had been opened. The ADON also confirmed that a Levemir FlexPen (long acting insulin) was ordered on 03/03/2024 for a resident and that the manufacturer's expiration date was 01/31/2026. The ADON stated she is responsible for the medication room. She explained that stock medications are arranged with the oldest items in the front and newer items in the back. She reported that her inventory list indicated that stock medications would not expire until May, and she acknowledged that her list needed to be updated.Interview on 03/31/2026 at 3:19 PM with the Director of Nursing (DON) revealed that medications should not be expired in the medication room or in medication carts. She stated that unit managers check and audit medication carts weekly and that the ADON is responsible for the medication room.

Based on record review and staff interviews, the facility failed to ensure a complete and accurate medical record was maintained for one of three sampled Residents (R1) reviewed for skin conditions. Specifically, R1's medical record did not contain documentation of all care planned skin assessments or consistent documentation of the completion of ordered skin treatments.Findings include:Review of R1's admission Record revealed, the resident had a medical history that included a diagnosis of acute kidney failure.Review of R1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/21/2025 revealed, R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment.Review of R1's Care Plan Report included a focus area, initiated 6/14/2023 and revised 3/12/2025, that indicated the resident was incontinent and at risk for complications, including skin irritation and rashes. A focus area, initiated 3/2/2023 and revised 4/6/2023, indicated the resident was at risk for decreased quality of life related to their inability to perform activities of daily living (ADLs) independently. An intervention dated 3/2/2023 directed staff to assess for any signs and symptoms of skin breakdown, scratches, bruises, open areas, or cuts during care activities and report to a nurse. A focus area, initiated 5/30/2025, indicated R1 had a new diagnosis of candidiasis (a fungal infection typically on the skin or mucous membranes caused by candida). An intervention dated 5/30/2025 directed staff to monitor skin rashes for increased spread or signs of infection.Review of R1's Electronic Medical Record (EMR) revealed Skin Observation Tools were completed on 6/8/2025, 6/22/2025, 6/26/2025, 7/18/2025, 7/27/2025, 8/5/2025, and 8/11/2025. The resident's EMR contained no documented evidence that Skin Observation Tools were completed on 6/15/2025, 7/6/2025, 7/13/2025, 8/3/2025, or 8/10/2025.During an interview on 8/13/2025 at 7:19 am, License Practical Nurse (LPN) #1 stated she worked on 7/6/2025, 7/20/2025, and 8/3/2025 and completed R1's skin assessments but failed to document they were completed because she got busy. Review of R1's 7/2025 and 8/2025 Treatment Administration Records (TARs) revealed the transcription of an order started on 7/2/2025 for triamcinolone acetonide cream (a steroid cream) 0.1 percent (%) to be applied topically to affected areas two times a day for itching. The TARs revealed the triamcinolone cream was scheduled to be administered each day at 9:00 am and 6:00 pm. The resident's 7/2025 and 8/2025 TARs revealed no documentation to indicate whether the treatments were administered as ordered on the following dates and times: 6:00 pm on 7/2/2025 and 7/3/2025, 6:00 pm on 7/5/2025 through 7/11/2025, 6:00 pm on 7/16/2025 and 7/17/2025, 6:00 pm on 7/21/2025, 6:00 pm on 7/24/2025 and 7/25/2025, 6:00 pm on 7/27/2025, 6:00 pm on 7/30/2025, 6:00 pm on 8/7/2025 and 8/8/2025, and 6:00 pm on 8/11/2025.During an interview on 8/12/2205 at 7:02 pm, LPN #3 stated she was assigned to provide R1's ordered triamcinolone treatments at 6:00 pm on 7/6/2025, 7/7/2025, 7/8/2025, 7/10/2025, 7/11/2025, 7/16/2025, 7/17/2025, 7/21/2025, 7/25/2025, 7/27/2025, 7/30/2025, and 8/8/2025. She stated she remembered completing the treatments on each of these dates. She stated she had been trained to sign the TAR after completion of ordered treatments, but she failed to do so before the end of each of her shifts.During an interview on 8/13/2025 at 1:05 pm, LPN #4 stated she was responsible for providing R1's treatments at 6:00 pm on 7/2/2025 and 7/3/2025. She stated she completed the treatments on those dates but failed to go back to the TAR and sign them off after she completed the treatments.During an interview on 8/13/2025 at 10:15 am, LPN #5 stated she was assigned to complete R1's ordered triamcinolone treatments at 6:00 pm on 7/24/2025 and 8/7/2025. She stated she completed the treatments but forgot to sign the TAR after she completed them.During an interview on 8/13/2025 at 12:45 pm, the Regional Nurse Consultant (RNC) stated she expected all skin assessments to be completed weekly and all treatments to be completed as ordered and both were to be documented to reflect timely completion.During an interview on 8/13/2025 at 2:00 pm, the Administrator stated R1's skin assessments should have been documented. The Administrator also stated staff should document the completion of skin treatments after the treatments were provided.

Based on observations, staff interviews and review of the facility policy titled, Food Storage, the facility failed to ensure that all opened food was labeled and dated. The deficient practice had the potential to affect all residents who were on an oral diet. Findings include: Review of the facility policy titled Food Storage revealed under POLICY: It is the policy of the Food and Nutrition Department that food storage occur in a strictly defined manner as outlined in the procedures below, PURPOSE: To prevent the transmission of disease carrying organisms. ACTION: .2. Stock is rotated so that older items are used first. Products are dated to assure First-In, First-Out procedure is followed. Observation during a tour of the kitchen on 4/14/2025 at 9:45 am revealed the following: Pork sausages, chicken breasts, chicken nuggets, French fries, okra, crispy fried onions, located in the freezer, were not labeled or dated. In an interview on 4/14/2025 at 9:45 am with the [NAME] confirmed that there should be an open date and a use by date labeled on items that have been opened. In an interview on 4/14/2025 at 9:50 am with the Assistant Dietary Manager confirmed that all kitchen staff were responsible to label opened food items.

Based on observations, staff interviews, record review, and review of the facility policy titled, Standard Precautions the facility failed to ensure infection control practices were followed for two of eight residents (R) (R37 and R84) during wound care, the facility failed to ensure infection control practices were followed when disposing of used Personal Protective Equipment (PPE), and the facility also failed to ensure infection surveillance was conducted monthly. The deficient practices had the potential to affect all residents residing in the facility. Findings include: Review of the facility policy titled Standard Precautions dated October 2018 revealed under Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1. Record review revealed R37 was admitted to the facility with diagnoses of but not limited to generalized muscle weakness, lack of coordination, moderate protein calorie malnutrition, and pressure ulcer of sacral region stage four. Review of the physicians orders located in the Electronic Medical Record (EMR) revealed a treatment order for the Sacrum: Cleanse with normal saline, pat dry, apply Santyl (wound treatment) then collagen, cover with dry protective dressing such as bordered gauze daily and PRN (as needed) per dislodgement/soiling. Review of the care plan for R37 revealed under focus: R37 has present skin breakdown as follows and is at risk for complications related to skin breakdown such as infection, increased pain, inability to participate in activities and socialization, anxiety/mood disorders. Coccyx: Stage 4 pressure wound. Goals included: Present skin breakdown will be healed without complications by next review date. Wound care observation of R37 on 4/12/ 2025 at 11:05 am with the Wound Care Nurse revealed the nurse proceeded to cleanse the wound care tray with a germicidal wipe and allowed it to air dry, after the tray was dry, the nurse proceeded to place a barrier on the tray before placing wound treatment supplies for treatment that included normal saline in a 30 ml (milliliter) cup, Medi fil II Collagen (wound treatment), Santyl ointment (the two were mixed together in 30 ml plastic medicine cup to make a paste), dry gauze, and bordered gauze. The Wound Care Nurse proceeded to sanitize hands with hand sanitizer and donned (put on) a gown and clean gloves after entering R37's room. The nurse informed R37 that wound care treatment was being completed and permission for surveyor to observe was obtained. The nurse pulled the privacy curtain, however the residents blinds were pulled up with full view from the courtyard. Residents brief was loosened, and resident was turned to the right side, old dressing was removed and area was cleaned. The area measured 0.3 cm (centimeters) X 0.1 cm X 0.1 cm; wound bed was not visible due to area being more of a pin hole shape. The nurse proceeded to wash hands with soap and water and new gloves were applied, resident was rolled back over on to his back, and the nurse returned to the resident and proceeded to apply paste of Santyl and collagen without recleaning area to buttocks and applied a dressing. Record review for R84 revealed resident was admitted to the facility with the diagnoses of but not limited to dementia, history of falling, essential hypertension, hyperkalemia, lack of coordination, and unsteadiness on feet. Review of the physician orders for R84 in the EMR revealed an order to cleanse the sacral area with normal saline, pat dry, apply Santyl, cover with dry protective dressing daily and prn per dislodgement/soiling. Review of the care plan revealed a focus of R84 has present skin breakdown upon admission and is at risk for complications related to skin breakdown such as infection, increased pain, inability to participate in activities and socialization Unstageable to Sacrum Stage III L (left) Upper Buttock. Goals included Present skin breakdown will improve without complications by next review date. Wound care observation on 4/12/ 2025 at 10:40 am with the Wound Care Nurse revealed the nurse proceeded to cleanse wound care tray with a germicidal wipe and allowed it to air dry, after the tray was dry, the nurse proceeded to place a barrier on the tray before placing wound treatment supplies for treatment that included normal saline in a 30 ml cup, Santyl ointment, Medi-honey (wound treatment), bordered gauze, Medi-pore tape, dry gauze, tongue blades, measuring tape, and a bag for dirty wound products used. The nurse proceeded to sanitize hands with and donned gown and clean gloves after entering the resident's room. The nurse informed R84 that wound care treatment was being completed and permission for surveyor to observe was obtained. R84's bed was repositioned and the nurse proceeded to remove the G-tube (gastrostomy tube placed in abdomen for feeding) dressing from stoma site without providing privacy. The residents privacy curtain remained open in view of resident's roommate as well as the blinds were open during the start of the treatment. After removing the dressing from the insertion site and cleaning area, the nurse proceeded to wash hands with soap and water and donned clean gloves before applying a clean dressing. R84's brief was loosened, and the resident was repositioned to the right side, curtains still open and window blinds open as well. The old dressing was removed, no drainage was noted on the dressing removed. The area to the sacrum wound base was pale pink in color and the area measured 1 cm x .03 cm x.01 cm, no drainage was noted during observation. The nurse proceeded to go to the bathroom to wash hands with soap and water. During this time R84 was left unattended by staff and rolled back on his back. The nurse returned from the bathroom and donned clean gloves, the resident was repositioned from his back to his right side, and the nurse applied the clean bandage without ensuring the wound area was cleaned again after resident was on the contaminated linens. Interview on 4/12/2025 at 11:30 am with the Wound care Nurse revealed that she was able to verbalize the wound care treatment process. During the interview, the Wound Care Nurse acknowledged that she did not clean R37's wound after the resident had rolled back on to the contaminated bed linens. Interview on 4/12/2025 at 1:30 pm with the Director of Nursing (DON) revealed that her expectation was for infection control practices to be followed at all times. During the interview it was disclosed that she expected the wound care nurse to ask for assistance with residents that have concerns with mobility and needed assistance with positioning while conducting wound treatments. 41165 2. Record review for R45 revealed resident was admitted to the facility with diagnoses of but not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of the physician's order in the EMR revealed the following order for the Sacrum Wound: Cleanse with NS, pat dry, apply Santyl then collagen, cover with dry protective dressing such as bordered gauze dressing daily and PRN per dislodgement/soiling. Wound care observation for R45 at 11:26 am revealed LPN II sanitized her hands, donned gloves, sanitized plastic tray, and placed a paper chux pad on top of the tray. LPN II removed a bottle of saline, 30 cc plastic cup, gauze, bordered dressing, Santyl, and collagen paste from the treatment cart and placed the items on top of the tray. LPN II removed gloves, sanitized hands, donned gloves and donned gown. LPN II removed the gown and threw it in the trash can stating that she forgot the gauze. LPN II returned to the treatment cart, sanitized hands and removed 4x4 gauze from the cart. LPN II returned to the room, sanitized hands, and donned gloves and gown. LPN II placed the tray with treatment supplies on top of R45's feet. LPN II removed the tray from R45's feet and held the tray in her right hand. LPN II, while holding the tray in her right hand, used her left hand to unclamp R45's catheter bag from the bed. LPN II threw the catheter bag on the bed near R45's feet. LPN II again placed the tray on R45's bed near her right foot. LPN II rolled R45 on to her left side, removed gloves, washed her hands and donned gloves. LPN II removed the old dressing, removed gloves, washed her hands, and donned gloves. The window blinds were observed to be open. The window showed full vision of the front parking lot and front porch. LPN II continued with wound care cleaning the sacral area. LPN II measured the area, removed gloves, washed hands, donned gloves and applied the Santyl/collagen mixture as ordered, and covered area with a dressing. LPN II removed the tray from R45's bed and held it in her left hand. With her right hand, LPN II attached the foley catheter bag back to the bed. With the tray in her left hand, LPN II moved the bedside table, removed gloves, and put the tray on top of treatment cart. LPN II then removed gown and threw it in the trash can. With ungloved hands, LPN II removed two gowns from the trash can and folded them up and exited the room with the unbagged gowns stating that she was taking the gowns to the laundry because they were re-washable. LPN II did not wash/sanitize hands after removing gloves, and she did not sanitize the tray before placing it back on the treatment cart. Interview with LPN II on 4/12/2025 at 3:32 pm revealed she acknowledged that she transported the soiled gowns down the hall to the laundry room in her ungloved hands, unbagged. LPN II stated that she should have placed the gowns in a plastic bag to transport to the laundry room. Interview with the DON on 4/12/2025 at 3:47 pm revealed the DON stated that her expectations were for infection control be followed before, during, and after wound care. 49675 3. Record review revealed the facility failed to complete surveillance by not calculating infection control rates for the months of January, February, and March of 2025. In addition, there was no evidence the facility had reviewed its infection control policies annually. Interview on 4/12/2025 at 10:30 am with the Infection Control Preventionist (ICP) revealed when asked about infection rates, she said she does not calculate infection rates. She said she looked at monthly infections and based education and training on what was going on in the facility. She said she had never been taught how to calculate the rate and that the prior DON and/or corporate office was figuring the monthly infection rates. She verified that surveillance relating to infection rates had not been done from January through March 2025. She revealed she did not know when the infection control policies were last reviewed. Interview on 4/13/2025 at 11:30 am with the Administrator revealed he did not know whether surveillance related to infection rates were currently being completed. In addition, he did not know the last time the infection control policies were last reviewed, stating they were not done annually. Interview on 4/13/2025 at 11:35 am and 1:31 pm with the DON revealed that she started in February 2025. She stated she cannot find where any surveillance related to infection rates were being completed since she got to the facility and planned on training the ICP on how to do it. She revealed she had no idea when the last time the infection control policies were last reviewed.

Based on observations, staff interviews, record review, and the review of the facility policies titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol and Residents Federal and State Rights, the facility failed to ensure four of eight residents (R) (R37, R84, R11, and R45) were provided privacy during wound care treatment. Specifically, the facility failed to ensure R37, R84, R11, and R45 full privacy was provided by ensuring window blinds were closed and the privacy curtains were fully engaged when conducting wound care treatments. Findings include: Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated April 2018 on page 5: Dressings, Dry/Clean under preparation. number 5. Explain procedure to the resident and provide privacy. Review of the facility's undated policy titled, Residents Federal and State Rights, revealed under Privacy and Confidentiality number 1. You have a right to personal privacy and confidentiality of your personal privacy which includes privacy in accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and residents groups.Number 5. You have a right to respect and privacy in your medical, personal, and bodily care program. Your care discussion, consultation, examination, treatment, and care shall be confidential and shall be conducted in privacy. 1. Record review for R37 revealed resident was admitted to the facility with the diagnoses of but not limited to generalized muscle weakness, lack of coordination, moderate protein calorie malnutrition, and pressure ulcer of sacral region stage four. Review of the physicians orders located in the Electronic Medical Record (EMR) revealed a treatment order for the Sacrum: Cleanse with normal saline, pat dry, apply Santyl (wound ointment) then collagen, cover with dry protective dressing such as bordered gauze daily and PRN (as needed) per dislodgement/soiling. Review of the care plan for R37 revealed under focus: R37 has present skin breakdown as follows and is at risk for complications related to skin breakdown such as infection, increased pain, inability to participate in activities and socialization, anxiety/mood disorders. Coccyx: Stage 4 pressure wound. Goals included: Present skin breakdown will be healed without complications by next review date. Wound care observation on R37 on 4/12/ 2025 at 11:05 am with the Wound Care nurse revealed the nurse proceeded to cleanse wound care tray with a Micro-kill germicidal wipe and allowed to air dry, after the tray was dry, the nurse proceeded to place a barrier on the tray before placing wound treatment supplies on it for treatment that included normal saline in a 30 ml (milliliter) cup, Medi fil II Collagen, Santyl ointment (the two were mixed together in 30 ml plastic medicine cup to make a paste), dry gauze, and bordered gauze. The Wound Nurse proceeded to sanitize hands with hand sanitizer and donned (put on) a gown and clean gloves after entering the residents room. The Wound Nurse informed R37 that wound care treatment was being completed and permission for surveyor to observe was obtained. The Wound Nurse pulled the privacy curtain; however the residents' blinds were pulled up with full view from the courtyard. During the observation it was noted that full privacy was not provided to the resident while treatment was being conducted. Interview on 4/12/2025 at 11:30 am with the Wound Care Nurse revealed that she was able to verbalize the process of the wound care treatment process. During the interview, the Wound Care Nurse acknowledged that full privacy was not provided for R37 during the wound dressing change. The staff member stated that she was not thinking about closing the blinds while the treatment was being conducted. Interview on 4/12/2025 at1:30 pm with the Director of Nursing (DON) revealed that her expectations was for whenever there was any kind of care being provided to the residents, that full privacy was provided, including the full engagement of the privacy curtains and ensuring that the blinds were closed for residents that were next to the window. During the interview, the DON also disclosed that infection control practices were expected to be followed during wound care treatments. 41165 2. Record review for R84 revealed resident was admitted to the facility with the diagnoses of but not limited to dementia, history of falling, essential hypertension, hyperkalemia, lack of coordination, and unsteadiness on feet. Review of the physician's order in the EMR revealed an order to cleanse the sacral area with normal saline, pat dry, apply Santyl, cover with dry protective dressing daily and prn per dislodgement/soiling. Review of the care plan revealed a focus of R84 has present skin breakdown upon admission and is at risk for complications related to skin breakdown such as infection, increased pain, inability to participate in activities and socialization Unstageable to Sacrum Stage III L (left) Upper Buttock. Goals included present skin breakdown will improve without complications by next review date. Wound care observation of R84 on 4/12/2025 at 10:40 am with Wound Care Nurse revealed the nurse proceeded to cleanse the wound care tray with a Micro-kill germicidal wipe and allowed it to air dry, after the tray was dry the nurse proceeded to place a barrier on the tray before placing wound treatment supplies for treatment that included normal saline in a 30 ml (milliliter) cup, Santyl ointment (wound ointment), Medi-honey (wound medication), bordered gauze, Medi-pore tape, dry gauze, tongue blades, measuring tape, and a bag for dirty wound products used. The Wound Care Nurse proceeded to sanitize hands with sanitizer and donned a gown and clean gloves after entering the resident's room. The Nurse informed R84 that wound care treatment was being completed and permission for surveyor to observe was obtained. R84's bed was repositioned and the nurse proceeded to remove the G-tube (gastrostomy tube-inserted into abdomen for feeding) dressing from stoma (opening in abdomen) site without providing privacy. The resident's privacy curtain remained open in view of the resident's roommate as well as the blinds were open during the start of the treatment. After removing the dressing from the insertion site and cleaning the treatment area, the nurse proceeded to wash hands with soap and water and donned clean gloves before applying a clean dressing. R84's brief was loosened, and the resident was repositioned to the right side, curtains still open and window blinds open as well. The old dressing was removed, no drainage was noted on the dressing removed. The area to the sacral wound base was pale pink in color, area measured 1 x .03 cm (centimeters) x .01 cm, no drainage was noted during observation. The nurse proceeded to wash hands with soap and water and donned clean gloves before applying a clean bandage. R84was repositioned back to his back. The Wound Care Nurse completed the treatment on R84 without providing privacy during the total process. 3. Record review for R11 revealed resident was admitted to the facility with diagnoses of but not limited to cerebral infarction, unspecified, unspecified diabetes mellitus without complications. Review of the physician's order in the EMR revealed the following order: Lt (left) Ankle Lateral (away from middle or center): Cleanse with WC (wound cleanser) or NS (normal saline), pat dry, apply gentamicin 0.1% ointment, cover with dry protective dressing such as ABD (abdominal) pad then rolled gauze with tape daily and PRN per dislodgement/soiling. Wound care observation for R11 at 11:48 am, performed by Licensed Practical Nurse (LPN) II revealed LPN II sanitized her hands, donned gloves, sanitized plastic tray, placed a paper chux (protective pad) pad on top of the tray, and then removed a bottle of saline, 30cc (cubic centimeter) plastic cup, gauze, bordered dressing, rolled gauze, and gentamycin ointment from the treatment cart and placed the items on top of the tray. LPN II stated that she was not going to use the rolled gauze as ordered because when R11 rubs her legs together it might come off. She stated that she knew that there was a PRN order to replace if dressing becomes dislodged, but she did not do it because she didn't use the rolled gauze. LPN II removed gloves, sanitized hands, donned gloves, put on a gown, and repositioned R11 in the Geri-chair (geriatric recliner). LPN II removed the boot from R11's left foot and asked the resident where the dressing to her left foot was. R11 was sitting in a Geri-chair near the window. The window blinds were observed to be open. The window showed full vision of the front parking lot and front porch. There were visitors entering and exiting the facility. There was a resident sitting in the front parking lot in her wheelchair facing R11's room window. LPN II continued with wound care, cleaning the area to the left heel. LPN II washed hands, donned gloves, and applied gentamycin ointment as per MD order. LPN II covered the wound with a bordered dressing. LPN II again stated that she was not going to use the ordered rolled gauze. LPN removed gloves, removed gown and placed the gown in a trash can. LPN II removed the gown from the trash can and exited the room stating that she was going to put the gown in the laundry. 4. Record review for R45 revealed resident was admitted to the facility with the diagnoses of but not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of the physician's order in the EMR revealed the following order to Sacrum Wound: Cleanse with NS, pat dry, apply Santyl then collagen, cover with dry protective dressing such as bordered gauze dressing daily and PRN per dislodgement/soiling. Wound care observation for R45 on 4/12/2025 at 11:26 am revealed LPN II sanitized her hands, donned gloves, sanitized plastic tray, and placed a paper chux pad on top of the tray. LPN II removed a bottle of saline, 30cc plastic cup, gauze, bordered dressing, Santyl, and collagen paste from the treatment cart and placed the items on top of the tray. LPN II removed gloves, sanitized hands, donned gloves and gown. LPN II removed the gown and threw it in the trash can stating that she forgot the gauze. LPN II returned to the treatment cart, sanitized hands and removed 4x4 gauze from the treatment cart. LPN II returned to the room, sanitized hands, donned gloves and gown. LPN II placed the tray with treatment supplies on top of R45's feet. LPN II removed the tray from R45 feet and held the tray in her right hand. LPN II, while holding the tray in her right hand, used her left hand to unclamp R45's catheter bag from the bed. LPN II threw the catheter bag on the bed near R45 feet. LPN II again placed the tray on R45's bed near her right foot. LPN II rolled R45 on to her left side, removed gloves, washed her hands and donned gloves. LPN II removed the old dressing, removed gloves, washed her hands, and donned gloves. The window blinds were observed to be open. The window showed full vision of the front parking lot and front porch. There were visitors entering and exiting the facility. There was a resident sitting in the front parking lot in her wheelchair facing R45's room window. LPN II continued with wound care cleaning the sacral area. LPN II measured the area, removed gloves, washed hands, donned gloves and applied the Santyl/collagen mixture as per order, and covered area with a dressing. LPN II removed the tray from R45's bed and held it in her left hand. With her right hand, LPN II attached the foley catheter bag back to the bed. With the tray in her left hand, LPN II moved the bed side table, removed gloves, and put tray on top of treatment cart. LPN II then removed the gown and threw it in the trash can. With ungloved hands, LPN II removed two gowns from the trash can and folded them up and exited the room with the unbagged gowns, stating that she was taking the gowns to the laundry because they were re-washable. LPN II did not wash/sanitize hands after removing gloves, and did not sanitize the tray before placing it back on the treatment cart. Interview with LPN II on 4/12/2025 at 3:32 pm revealed LPN II acknowledged that full privacy was not provided for R11, and full privacy was not provided for R45 during the wound dressing change . LPN II stated that she was not thinking about closing the blinds while the treatment was being conducted, but she did ask the residents if it was ok for the surveyor to watch the treatment. Interview with the Director of Nursing (DON) on 4/12/2025 at 3:47 pm, the DON stated that her expectation was for privacy to be provided to the residents during wound care to include closing the privacy curtains and closing the window blinds.

Based on observations, record review, staff interviews, and review of the facility policy titled, Environment Rounds/Repairs, the facility failed to ensure that the environment was safe, clean, comfortable, and homelike in two rooms on A hall (room [ROOM NUMBER] and room [ROOM NUMBER]) located on two of four halls. Specifically, plaster on the wall was missing and cracked in two areas on Hall C, and chipped floor tile, black marks on privacy curtains, and a dirty feeding pump pole were noted on hall A. Findings include: 1. Review of the facility policy titled Environmental Rounds/ Repair revealed under Policy Statement: name of facility is committed to maintaining a home-like environment and to repair issues in acceptable time frame. Under Procedures: Maintenance Director will make environmental rounds every week. Any noted areas that are in need of repair will be repaired as soon as possible.Facility also has a part-time painter employed who is available to repair sheet-rock issues and paint and/or retouch as needed. Observation on 4/12/2025 at 9:51 am on C hall before entering D Hall by the double doors, the corner wall needed to be repaired. Plaster was missing and cracked in the area before the handrail. The wall near room [ROOM NUMBER] had missing plaster. Interview on 4/13/2025 at 11:28 am with the Maintenance Director confirmed that the plaster needed to be repaired on both walls and that he would repair both walls. He stated that staff could have reported this using the facility name Repair Requisition form. He revealed that this form could be completed by any staff. This form could be found behind the nurse's station. 41165 2. During the initial tour of the facility on 4/11/2025 at 8:40 am the following environmental concerns were observed on A hall: room [ROOM NUMBER] revealed chipped floor tile near A bed, and the privacy curtain observed with black marks on the front and yellowish stains on the back. room [ROOM NUMBER] revealed a feeding pump with a dried, brownish substance on the pole. There was also a dried, brownish substance observed on the floor around and near the feeding pump pole. Observations throughout the day revealed the environmental issues remained. Observations on 4/12/2025 at 7:30 am revealed environmental issues remained. Environmental issues (dried substance on feeding pump, pole) observed were verified by Housekeeper (HK) CC on 4/12/2025 at 9:30 am. Environmental issues (dried substance on feeding pump, pole, floor, privacy curtain) observed were verified by the Director of Nursing on 4/12/2025 at 9:58 am. Environmental issues (dried substance on feeding pump, pole, floor, privacy curtain) were verified with the Housekeeping Supervisor HK BB on 4/12/2025 at 10:44 am. Environmental issues (chipped floor tile) were verified with the Maintenance Director (MD) on 4/13/2025 at 8:58 am. Interview with HK CC on 4/12/2025 at 9:30 am revealed HK CC just finished mopping the room and placed a wet floor sign at the door. HK CC stated that the brownish substance on the floor and feeding pump and pole looked like milk that had dried up. She stated that she would probably be the one to clean it up. She stated that she mops fast because the Certified Nursing Assistants (CNA) were in and out the room. Interview with the Director of Nursing (DON) on 4/12/2025 at 9:58 am, the DON stated that the nurses were responsible for cleaning the feeding pump and pole. She stated that housekeeping was responsible for cleaning the floor. The DON further stated that the brownish substance observed on the feeding pump, pole, and floor looked like dried tube feeding formula. Interview with the Housekeeping Supervisor HK BB on 4/12/2025 at 10:44 am, HK BB revealed she expected the housekeepers to clean the floor. She stated that maintenance takes the curtains down and changes them. Interview with the Maintenance Director (MD) on 4/13/2025 at 8:58 am revealed he was not aware of the chipped floor tile. He stated that they have a box with communication slips that staff used to communicate any maintenance/environmental issues. He revealed there was no slip addressing the chipped floor tile.

Based on observations, staff interviews, record review, and review of the facility policies titled, Care Planning- Interdisciplinary Team and Care Plans, Comprehensive Person-Centered, the facility failed to ensure a care plan for oxygen use was developed for one of nine residents (R) (R52) using oxygen. The facility also failed to ensure a care plan was developed for one of three residents, R35 that had an indwelling catheter. The deficient practice had the potential to increase the probability of R52 and R35's needs not being met according to their care needs. Findings include: Review of the facility policy titled Care Planning- Interdisciplinary Team dated March 2022 revealed under Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Under Policy Interpretations and Implementation number 2. Comprehensive person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Review of the facility policy titled Care Plans, Comprehensive Person- Centered dated March 2022 revealed under Policy Statement: A Comprehensive, person-centered care plan that includes measurable objectives and time tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each residents. 1. Record review revealed R52 was admitted to the facility with diagnoses of Parkinson's disease, essential hypertension, anxiety disorder, and depression. Review of the physician orders located in the Electronic Medical Record (EMR) system under orders revealed an order for oxygen (02) via nasal cannula (NC) at 2 liters per minute (LPM) as needed for Shortness of Breath (SOB), wheezing or 02 Saturations (Sats) <92% (under 92 percent). Review of the care plan for R52 did not indicate O2 use was being utilized. Review of the Quarterly Minimum Data Set (MDS) for R52 dated 2/28/2025, Section O (Special Treatments) indicated that resident was receiving O2 therapy while in facility. Review of the resident care plan initiated 12/2024 did not indicate O2 use for R52. Interview on 4/12/2025 at 3:10 pm with MDS Coordinator DD revealed that the MDS team were responsible for ensuring that the resident's care plans were developed and updated. During the interview, it was confirmed that R52 did not have a care plan developed for the current use of O2. Interview on 4/12/2025 at 3:30 pm with the Director of Nursing (DON) revealed that her expectation was for each resident to have a comprehensive care plan that identified all of their care areas and to ensure the residents' needs were met. During the interview it was confirmed that R52 did not have a care plan that was developed in reference to her O2 usage. 41165 2. Record review revealed R35 was admitted to the facility with diagnoses of but not limited to displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture without healing, chronic kidney disease, stage 3, unspecified, cystitis, unspecified with hematuria. Review of the physician orders for R35 located in the EMR system under Orders revealed an order for an indwelling foley catheter for Urinary Retention, 16 fr (French- catheter size) with 10 ml (milliliter) balloon to bedside drainage. Review of the Quarterly MDS for R35 dated 1/9/2025 Section H (Bladder and Bowel) indicated that resident had an indwelling foley catheter. Review of the resident care plan last revised on 2/15/2025 did not indicate R35 had an indwelling foley catheter. Interview on 4/12/2025 at 4:12 pm with MDS Coordinator DD revealed that the MDS team were responsible for ensuring that the resident's care plans were developed and updated. She stated that she communicated with the nursing team, but MDS was responsible for putting the foley catheter in the care plan. During the interview, it was confirmed that R35 did not have a care plan developed for an indwelling foley catheter. MDS Coordinator DD stated that she was going to put a care plan in for R35. Interview on 4/12/2025 at 4:30 pm with the DON revealed that her expectation was for each resident to have a comprehensive care plan that identified all of their care areas and to ensure the residents needs were met. During the interview it was confirmed that R35 did not have a care plan that was developed for indwelling foley catheter.

Based on observations, record review. and staff interviews, the facility failed to follow the Physician Orders related to wound care for one of four residents observed during wound care (R11). The deficient practice had the potential for R11's wound to worsen. Findings include: Record review for R11 revealed resident was admitted to the facility with diagnoses of but not limited to cerebral infarction, unspecified, unspecified diabetes mellitus without complications. Review of the Physician's orders in the Electronic Medical Records (EMR) revealed the following order: Lt (left) Ankle Lateral: Cleanse with WC (wound cleanser) or NS (normal saline), pat dry, apply gentamicin 0.1% ointment (antibiotic), cover with dry protective dressing such as ABD (abdominal) pad then rolled gauze with tape daily and PRN (as needed) per dislodgement/soiling. Wound care observation for R11 on 4/9/2025 at 11:48 am performed by Licensed Practical Nurse (LPN) II revealed she sanitized her hands, donned (put on) gloves, sanitized plastic tray, placed a paper incontinence pad on top of the tray, and removed a bottle of saline, 30 cc (cubic centimeters) plastic cup, gauze, bordered dressing, rolled gauze, and gentamycin (antibiotic) ointment from the treatment cart and placed the items on top of the tray. LPN II stated that she was not going to use the rolled gauze as ordered because when R11 rubs her legs together it might come off. She stated that she knew that there was a PRN (as needed) order to replace if dressing becomes dislodged, but she did not do it because she didn't use the rolled gauze. LPN II removed gloves, sanitized hands, donned gloves, put on a gown, and repositioned R11 in the Geri-chair (geriatric recliner). LPN II removed the boot from R11's left foot and asked the resident where the dressing to her left foot was. LPN II continued with wound care cleaning the area to the left heel. LPN II washed hands, donned gloves, and applied gentamycin ointment as ordered. LPN II covered the wound with a bordered dressing. LPN II again stated that she was not going to use the ordered rolled gauze. LPN removed gloves, removed gown, and placed the gown in a trash can. LPN II removed the gown from the trash can and exited the room stating that she was going to put the gown in the laundry. Interview with the Director of Nursing (DON) on 4/12/2025 at 4:00 pm, the DON stated that the nurses must follow physician's orders. She stated that if physician's orders were not followed, it was a delay in care and would be neglect.

Based on observations, staff interviews, and record review, the facility failed to ensure an environment free from potential accident hazards by failing to properly secure an oxygen (O2) tank for one of 10 residents (R) (R28) receiving oxygen therapy. The deficient practice had the potential to harm R28 or other residents that could come in contact with the unsecured O2 tank. Findings include: A policy on accident hazards was requested, however the Director of Nursing (DON) revealed the facility did not have one. Review of R28's electronic medical record (EMR) revealed the resident was admitted with diagnoses of but not limited to acute respiratory distress and heart failure, unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Physician order's for R28 revealed an order dated for Oxygen as needed at two liters per minute (LPM). Observations on 4/11/2025 at 9:00 am and 3:00 pm revealed a free-standing, unsecured O2 tank located behind the resident's bed. Observation on 4/12/2025 at 9:15 am revealed a free-standing, unsecured O2 tank located behind the resident's bed. Interview on 4/12/2025 at 10:16 am with Certified Nurse Assistant (CNA) KK revealed that free- standing O2 tanks should not be stored in residents' rooms. She revealed that she must have forgotten to remove it after patient care. She revealed a free-standing tank could easily fall and injure someone. Interview on 4/12/2025 at 10:18 am with Registered Nurse (RN) II revealed she was unsure if the free-standing O2 tank should be in the resident's room because she had only been employed for four days. After asking another nurse, she revealed that a free-standing tank should not be stored in a resident's room due to the risk of injury. She revealed gases could escape and someone could be injured, and it could fall and hit the floor and cause injury. She had a CNA remove the tank. Interview on 4/12/2025 at 10:22 with the Director of Nursing (DON) revealed under no circumstances should a free-standing O2 tank be stored in a resident's room. She revealed the resident was admitted back into the facility with the tank approximately two weeks ago and the facility was waiting for an O2 concentrator, which was already present and working. She revealed the tank should have been removed from the resident's room.

Based on observation, staff interview, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure one of nine residents (R) (R52) oxygen (O2) was administered as ordered by the physician. Specifically, the facility to failed to ensure R52's O2 rate was set on 2 liters per minute (LPM) instead of 4 LPM via nasal cannula (NC). Findings include: Review of the facility policy titled, Oxygen Administration, dated October 2010 revealed under Preparation, number 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review revealed R52 was admitted to the facility with diagnoses of Parkinson's disease, essential hypertension, anxiety disorder, and depression. Review of the physician orders for R52 located in the Electronic Medical Record (EMR) system under Orders revealed an order for oxygen (02) via nasal cannula at 2 liters per minute as needed for Shortness of Breath (SOB), wheezing or 02 Saturations (Sats) <92% (under 92 percent). Review of the care plan for R52 did not indicate O2 was being utilized. Review of the Quarterly Minimum Data Set (MDS) for R52 dated 2/28/2025 Section O (Special Treatments) indicated that resident was receiving oxygen therapy while in facility. Observation on 4/11/2025 at 8:30 am revealed R52's O2 concentrator set on 4 LPM. Resident was receiving O2 via NC. Observation on 4/11/2025 at 3:00 pm revealed R52's O2 concentrator set on 4 LPM. Resident continued to receive O2 via NC. Observation on 4/12/2025 at 11:30 am revealed R52's O2 concentrator set on 4 LPM. Resident was receiving O2 via NC. Interview on 4/12/2025 at 11:35 am with Licensed Practical Nurse (LPN) AA revealed that the charge nurses were responsible for ensuring that the residents that were receiving O2 were receiving O2 as ordered by the physician. LPN AA confirmed that R52's O2 was set on 4 LPM and the order was for O2 to be delivered at 2 LPM as needed. Continued interview revealed that the O2 levels were checked once a day and that R52's concentrator had not been checked for the day. Interview on 4/12/2025 at 3:30 pm with the Director of Nursing (DON) revealed that residents that were receiving O2 therapy flow rates should be checked throughout the day to ensure that the correct amount of ordered O2 was being delivered. During the interview the DON confirmed that R52 had a current order for O2 at 2 LPM and not 4 LPM. The DON also confirmed that R52 did not have a care plan that addressed the use of O2 therapy.

Based on staff interview and record review the facility failed to ensure that six residents ((R) R#66, R#67, R#74, R#126, R#176, R#276) of 8 residents reviewed had completed pneumococcal consent forms and received pneumococcal vaccines in a timely manner. Findings include: 1.Review of record revealed R#276 was admitted to the facility 9/2/22. The Pneumococcal consent form is incomplete, it is not circled do or do not consent. During an interview on 9/14/22 at 12:52 p.m. with the Infection Control Preventionist (ICP) it was stated that she is not sure rather R#276 wants the pneumococcal vaccine. ICP expressed that she has not followed up to clarify with R#276, and she has not checked GRITS to see if he has already had the pneumococcal vaccine. 2.Review of record revealed R#66 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to pneumococcal vaccine on 8/24/22. Review of record revealed resident has not received the pneumococcal vaccine as of 9/14/22. This was verified by ICP. 3.Review of record revealed R#67 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the pneumococcal vaccine on 8/9/22. Review of record revealed resident has not received the vaccine as of 9/14/22. This was verified by ICP 4.Review of record revealed R#176 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the pneumococcal vaccines on 8/30/22. Review of record revealed resident has not received the pneumococcal vaccine as of 9/14/22. This was verified by ICP. 5.Review of record revealed R#126 was admitted to the facility on [DATE]. Record review revealed resident's responsible party (RP) consented to receive pneumococcal vaccine on 9/1/22. Review of record revealed resident has not received the pneumococcal vaccine as of 9/14/22. This was verified by ICP. 6.Review of record revealed R#74 was admitted to the facility on [DATE]. The pneumococcal vaccine consent form is incomplete and does not identify if R#74 does or does not want to receive the pneumococcal vaccine. During an interview on 9/14/22 at 12:55 p.m. with the ICP who stated that she is not sure if R#74 wants or if he needs the vaccine as she has not checked the online immunization database. On 9/14/22 at 1:23 p.m. during an interview with the Administrator he revealed that it is his expectation that all residents and/or families who desires residents to be vaccinated receives the vaccines per their wishes. The Administrator stated that it is his expectation that residents get vaccinated as quickly as possible. The Director of Nursing (DON) is the back up for ICP and should be tracking resident's vaccines as well, but the ICP is responsible. The Administrator stated the missed vaccines were a result of human error. Administrator reported that the pneumococcal vaccines have been ordered from the pharmacy. On 9/14/22 at 3:05 p.m. during an interview with DON, she stated that the pneumococcal vaccines are kept at the facility and there should not be a delay in the pneumococcal vaccine administration. DONE

Based on staff interviews, record review, and review of policy titled Facility COVID-19 Vaccination Plan, the facility failed to ensure that five residents ((R) R#66, R#74, R#126, R#176, R#276) of eight residents reviewed received COVID-19 vaccines in a timely manner. Findings include: Review of the facility policy titled Facility COVID-19 Vaccination Plan (Updated 10/21/21) revealed: Purpose: To offer science-based information and vaccination to all staff, residents, and family members wanting to receive vaccination. Plan: When new residents are admitted to the facility, residents will be offered information from the CDC about [CONDITION(S)]-CoV-2 vaccine that is available to our facility through local health department and/or facility's pharmacy provider. Vaccination will be encouraged but not required. When resident is newly admitted , meeting will be held with family either virtually or in person. Same information from CDC about the [CONDITION(S)]-CoV-2 vaccine that is available to our facility through local health department and/or facility's pharmacy provider will be offered to family members of newly admitted resident. Vaccination will be encouraged but not required. Should resident, staff, or family members request vaccination, facility will procure requested vaccine from local health department or pharmacy. Resident, staff, or family member will be made aware of date of single dose vaccination or dates of two dose vaccinations. 1.Review of record revealed R#276 was admitted to the facility 9/2/22 on Transmission Base Precautions (TBP) Record revealed resident was place on place TBP because he had not been vaccinated. Review of record revealed that R#276 consented to receive the COVID vaccine on 9/2/22. On 9/14/22 at 12:27p.m. during an interview with R#276, he stated that he is on isolation because he has not been vaccinated. R#276 stated that he had COVID in February of this year and he doesn't want it no more. R#276 reported that he has signed to get the vaccine but has not received it yet and facility staff have not said anything else about it. On 9/14/22 at 12:52 p.m. during an interview with Infection Control Preventionist (ICP), she stated R#276 was admitted to facility on 9/2/22 and he consented to receive the COVID vaccine on admission. ICP also stated that she did not know he had consented to receive the COVID vaccine until today because she has been working as a charge nurse and as a Certified Nursing Assistant (CNA) to ensure residents are cared for. ICP stated that no one at the facility has looked at his consents or vaccination status. She further stated that she was at the facility Monday, 9/12/22, in the ICP role but has no gotten around to reviewing the vaccines. ICP stated, I don't have a reason for not looking at it, I was told today by the Admission Director that R#276 consented to the vaccine on admission. ICP stated that the Department of Public Health (DPH) must be notified and has not been informed of the need for the vaccine. ICP stated that a staff member from DPH comes to the facility to vaccinate residents the following Thursday once they are called and informed, they need the vaccine. On 9/14/22 at 1:03 p.m. during an interview with the Admissions Director, she revealed that R#276 wanted to get the COVID vaccine and she informed the ICP today. The Admissions Director further stated that she was not aware that R#276 had consented to be vaccinated until last Friday because she did not complete his admission paperwork. She further stated that once the paperwork for the vaccine is completed that someone from DPH comes to the facility to vaccinate the residents quick. The Admissions Director further stated that the paperwork for R#276 is not complete at this time. 2.Review of record revealed R#66 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the COVID vaccine boosters and pneumococcal vaccines on 8/24/22. Review of record revealed resident has not received the COVID vaccine as of 9/14/22. This was verified by ICP. 3.Review of record revealed R#176 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the COVID vaccine booster on 8/30/22. Review of record revealed resident has not received the COVID vaccine as of 9/14/22. This was verified by ICP. 4.Review of record revealed R#126 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the COVID vaccine boosters. Review of record revealed resident has not received the COVID vaccine as of 9/14/22. This was verified by ICP. 5.Review of record revealed R#74 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to receive the COVID vaccine booster on 8/26/22. Review of record revealed resident has not received the vaccine as of 9/14/22. This was verified by ICP. On 9/14/22 at 1:23 p.m. during an interview with the Administrator he revealed that it is his expectation that all residents and/or families who desires residents to be vaccinated receives the vaccines per their wishes. The Administrator further stated that someone at the facility should have contacted DPH to inform them of the facility's need for the COVID vaccine. The Administrator stated that it is his expectation that residents get vaccinated as quickly as possible. The Director of Nursing (DON) is the back up for ICP and should be tracking resident's vaccines as well, but the ICP is responsible. The Administrator stated the missed vaccines were a result of human error. He reported that he called DPH, and someone will be at the facility tomorrow to administer COVID vaccines. On 9/14/22 at 3:05 p.m. during an interview with DON, she stated the turn around with residents receiving COVID vaccines once DPH is informed is a few days. DONE

Based on observation, record review, resident and staff interviews, the facility failed to accommodate one resident (providing equipment to encourage self toileting at night), (R) R#57) of 20 sampled residents. Findings include: Record review revealed R#57 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] that revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. R#57 also noted to have functional limitation in range of motion in the lower extremity with impairment to one side. Review of record also revealed that resident was admitted to the facility for therapy after undergoing a recent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview with R#57 on 9/13/22 at 12:11 p.m., it was reported that previously she was in another room alone but was recently moved to this room with a roommate who ambulates and uses the bathroom. R#57 reported that it is now hard for her to get to the bathroom on time without urinating in her clothes which is embarrassing. R# 57 stated that she did not have this problem until her bedside commode was taken away. During further interview R#57 stated that she was told that she could no longer have the bedside commode because there was not enough space in the room for it. R#57 stated that she no longer needs the bedside commode during the day, but she needs it at night because she has a hard time getting up and getting to the bathroom due to her recent hip surgery. She further reported that the bedside commode was needed to be safe at night because she does not want to fall again. During an interview on 9/14 /22 at 10:44 am. with the Therapy Manager, she verified R#57 is safe to use the bedside commode. Therapy Manager stated that she informed R#57 today that the bedside commode was removed because she needed to ambulate to the bathroom as a progression to go home. Therapy Manager further reported that R#57 informed her that she had to wear a pull-up brief last night just in case she had an incontinent accident. During further interview with R#57 on 9/14/22 at 12:23 p.m., resident stated that when she had the bedside commode it was positioned in front of her dresser and not in the path of her roommate. R#57 stated that lady who removed the bedside commode told her that she was taking it and that she will have to use her walker and walk to the bathroom if she wants to go home. R#57 reported that she was told that she needed to stop depending on these devices. Resident stated that she was awake almost all night because she was afraid, she would urinate on herself. R#57 also reported that there were two other ladies that she is roommates with and sometimes they all have to go to the bathroom at the same time and that happened earlier in the day. I am afraid I am going to fall going to the bathroom in the middle of the night as well. R#57 stated that before she got the bedside commode that she urinated in the trash can at night and sometimes urinated on herself. During an interview with resident's roommate, R#49, on 9/14/22 at 9:11 a.m., she stated that she was not in the room yesterday when the bedside commode was removed from the room but acknowledged that R#57 had been using one. R#49 reported that R#57 has a hard time getting in the wheelchair to get to the bathroom and she needs that potty chair there by her bed. R#49 further stated that she witnessed R#57 turn her call light on at about 5 a.m. this morning for help to go to the bathroom, and a staff member responded to the light and told R#57 to get up and go, did not assist R#57, and did not turn the big light on so R#57 could see her way to the bathroom. During an interview with the Admissions Director on 9/14/22 at 10:40 a.m. she stated that she removed the beside commode because there was too much stuff in the room, and it was a fall risk for R#57 and her roommate. The Admissions Director further stated that she instructed R#57 to put her call light on and request assistance from the staff to go the bathroom when she needed to go during the night. During an interview with the Director of Nursing (DON) on 9/14/22 at 2:10 p.m., DON stated that R#57's plan is to go home so she needs to ambulate with the walker. DON further stated now that she in the room with another resident there is limited space and therapy said she is safe to go from the bed to the bathroom using the walker. DON further stated, we are trying to get her ready to live at home. She also stated, I am not saying she can't have a bedside commode when she goes home but she didn't have one prior to her fall at home. DON stated that she felt without the bedside commode it would not have taken up so much space in the room but if it's big of a deal we will put it back in there. DONE

Based on record review, resident and staff interviews, and policy titled, Admission, Transfer, and Discharge Policy & Procedure, the facility failed to notify the Physician or the responsible party of change in condition for one resident (R) R#18) of 4 residents transferred to the hospital. Findings include: Review of facility policy titled Admission, Transfer, and Discharge Policy & Procedure - (not dated) revealed the following: Notice Before Transfer - Before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative of the resident of the transfer or discharge. Record review of the medical record for R#18 revealed resident was sent out to the emergency roiagnom on [DATE]. Review of the Nurse's Notes dated 8/21/22 at 10:30 a.m. revealed R#18 was sent to the emergency room for evaluation and treatment after having a behavioral episode with another resident. There was no documentation to support that the responsible party or the Physician had been notified. An interview was conducted on 9/14/22 at 2:51 p.m. with the Director of Nursing (DON) who revealed that it is her expectation whenever there is a change in the resident's status or the resident is transferred out of this facility, the Physician is notified, an order is obtained, and the family representative is also notified. DON reviewed the Nurse's Notes for R#18 and confirmed there was no documentation that either the Physician or the family representative was notified of R# 18's transfer to emergency roiagnom on [DATE].