Every finding on record at Center at Zaragoza, LLC

Based on observation, interview and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #3) reviewed and 1 of 1 oxygen storage room reviewed for respiratory care. 1. The facility failed to check Resident #3's portable oxygen tank to ensure the oxygen tank was full when preparations were made to discharge the resident home on [DATE] to administered oxygen continuous at 2 L/min via nasal cannula. 2. The facility failed to ensure 21 oxygen metal cylinders, stored in the main oxygen storage room, were properly stored.These deficient practices could place residents at an increased risk of developing respiratory complications, a decreased quality of care not receiving oxygen support due to improper storage .The findings include: Record review of Resident #3's History & Physical, dated 5/04/26, revealed a [AGE] year-old male with a complex medical history of CHF (heart muscle becomes weakened or stiff and cannot pump blood efficiently to meet the body's needs), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure) , dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation), Pacemaker dependency (your heart's natural rhythm is so weak or absent that it can't keep your heart beating at a safe rate without the help of a pacemaker), Cirrhosis (permanent scarring of the liver), ESRD (end stage renal failure, last stage of kidney disease) on dialysis and Asbestosis (lung disease caused by breathing in asbestos fibers over a long period of time). Presented on 04/23/26 following a fall resulting in an acute right intertrochanteric femur fracture. Right hip surgical incision. admitted for Orthopedic/Rehab. Record review of Resident #3's admission MDS, dated [DATE], revealed, Entry date 05/04/26, admitted from acute hospital. Clear speech, makes self-understood, and understood others. Resident #3 had a BIMS Summary Score 9 (cognitively moderately impaired). Resident #3 used a Manual wheelchair and was Incontinent of Bowel & Bladder. Resident #3 had Active Diagnoses which included: CHF, hypertension (high blood pressure), cirrhosis (permanent scarring of the liver), ESRD (end stage renal failure, last stage of kidney disease), dementia (loss of thinking, memory, and reasoning abilities that interfere with daily life), sleep apnea (condition where your breathing repeatedly stops or becomes very shallow while you sleep, causing poor sleep quality and potential health risks). Recent surgery. Hip fracture and surgical wound. High-Risk Drug Classes: Antipsychotic, Anticoagulant, Antibiotic, and Opioid. Resident #3 received Oxygen therapy-while a resident. The resident's Overall Goal: Discharge to the community. Discharge Plan. discharge date 3 or fewer months away. Record review of Resident #3's Care Plan, initiated 05/04/26, revealed: -I am at respiratory risk related to my respiratory condition and/or my abnormalities in pulmonary function. Interventions: Administer oxygen as ordered. Monitor breath sounds as needed. Monitor for shortness of breath with exertion, edema (swelling caused by excess fluid building up in the tissues of your body) to extremities and c/o of dizziness and fatigue. -I want to establish goals for myself and to be involved in my discharge planning process. Interventions: Contact appropriate community agencies as needed when patient was ready for discharge. Record review of Resident #3's Physician's Order Summary, dated 06/02/26, revealed, Order Date: 06/01/26 Oxygen concentrator with portable device. Oxygen Order: 2 L/min continuously via nasal cannula. Length of time needed: Lifetime. Diagnosis: Respiratory Failure with hypoxia (your body or parts of it aren't getting enough oxygen), related to aspiration pneumonia (a lung infection that happens when food, drink, saliva, or stomach contents accidentally get into your lungs instead of your stomach). Record review of Resident #3's IDT notes, dated 05/03/26 to 06/03/2026, revealed:-Daily Nursing Note, dated 06/01/26 at 8:21 a.m., written by the DON revealed: Patient was evaluated for trial weaning from supplemental oxygen per current care plan and respiratory status assessment. Oxygen was gradually reduced while monitoring patient tolerance and oxygen saturation levels. During the attempt to wean, patient's oxygen saturation decreased below baseline parameters. Patient was observed to desaturate to 87% on room air. Patient remained alert but unable to maintain adequate oxygenation without supplemental oxygen. -Care Plan Note, dated 06/01/26, written by LVN Case Manager O, revealed Patient. will be discharged today with to[city, state] . Home H ealth referral sent and DME referral sent to provider. -Discharge Note, dated 06/01/26 at 11:51 a.m., written by LVN C, admission Coordinator revealed Education provided to prior to discharge on all medication administration and oxygen use. Patient discharged from facility at 11:51 a.m. Patient was discharged with private vehicle going back home to [city, state]. All medications and personal belongings sent with the patient and . 1. Record review of Resident #3's admission Record, dated 6/02/26 , revealed an admission date of 5/04/2026.Observation on 06/01/26 at 11:26 a.m. accompanied by the DON and admission Coordinator LVN C revealed Resident #3 was sitting in a wheelchair and the family member was pushing the wheelchair by the nurses station. It was observed the resident had a portable liquid oxygen tank hanging from the strap on the back of his wheelchair and a nasal cannula in place. admission Coordinator LVN C and the DON were talking to Resident #3 and . admission Coordinator LVN C said the resident was getting ready to be discharged home and was driving him back home . The admission Coordinator LVN C was asked to check the oxygen level in the portable liquid oxygen tank. LVN C said, This is how we check the level of liquid oxygen, by holding the tank by the straps and slightly tilt it to one side. She kept moving the tank from side to side and she said the contents indicator was not moving. It was observed the carrying strap had a plastic buckle located in the middle of the carrying strap that was not disengaged to check the liquid oxygen contents. She moved her hand on the strap nearest to the contents indicator and it was observed the contents indicator revealed the oxygen tank was empty. admission Coordinator LVN C said she was filling in for the RN X who was assigned to Resident #3 . She said she had taken over RN X's assignment at 10:00 a.m. and the resident's was already at the facility to take the resident home. She said she did not know if RN X filled the portable oxygen tank before she left. admission Coordinator LVN C said she had not checked the contents in the portable tank prior to the family member taking the resident out of the room to wheel the resident to their private vehicle to drive him back home. It was observed admission Coordinator LVN C immediately went to fill the portable liquid oxygen tank in the oxygen room located directly in front of the nurses station. The DON said the nurses were responsible for checking the portable oxygen tanks were full prior to discharging a resident and/or when residents went out to appointments. She said the risk of not checking the portable oxygen tank contents could result in the resident not receiving the prescribed oxygen and potential medical complications. During an observation and interview on 06/01/26 at 11:42 a.m., the resident's family member said she was not aware if the nurses checked Resident #3's portable oxygen tank prior to her wheeling the resident out of the room to take him to her truck to drive him back home . The family member said the resident was on continuous oxygen and it was a four-hour drive to get back home . She said the facility let her borrow one of their portable liquid oxygen tanks to take the resident back home. She said she had not checked the contents of the oxygen tank because she assumed the nurses had filled the oxygen tank prior to her taking him out of the facility to put him in her truck. During an interview and record review on 06/02/26 at 10:39 a.m. with the DON revealed Resident #3 had a physician's order to administer oxygen at 2 L/min when he was discharged home on [DATE] .During an interview on 06/02/26 at 10:45 a.m., LVN Case Manager O said she could not remember how many liters of oxygen were ordered for Resident #3 on the day of discharge, on 06/01/26. She said oxygen would need to be administered according to physician's orders and the nurse who was assigned to the resident at the time of discharge was responsible for checking the oxygen tank was full prior to discharging the resident. 2. During an observation and interview on 06/01/26 at 11:19 a.m. with Maintenance Supervisor B in the presence of the Executive Director revealed, there was a locked oxygen storage room that had a keypad lock. There were twenty-one H metal oxygen cylinders stored on the concrete floor and the oxygen cylinders were not physically chained to the wall or placed in a rack to prevent tipping in the same room where there were multiple large tanks of liquid oxygen stored. It was observed that nine of the H metal oxygen cylinders were stored on the floor, close to the entrance door to the oxygen room that was not secured or physically chained to the wall. The chain was on the cement floor on the opposite side of the room directly across from where the other 12 oxygen metal cylinders were. Maintenance Director B said, Those are not H tanks, they are K tanks and weigh 400 lbs . and do not need to be secured with a chain because it would be very difficult for tipping them over. There were three H metal oxygen cylinders that did not have the metal cylinder cap to cover the valve when the oxygen tank was not in use. A copy of the Oxygen policy related to the use of metal oxygen cylinders was not provided prior to exit . Record review of the facility's Liquid Oxygen Storage & Transfer Policy and Procedure, revised 02/08/21, provided by Maintenance Supervisor B revealed: Purpose - The Center aim to keep patients, guess and employee safe from hazardous exposure to liquid oxygen. Policy: The Center will follow the NFPA 99 standards for the safe storage, transfer and use of liquid oxygen. Procedure: Storage room must be kept locked against unauthorized entry. Floors must be ceramic or concrete.

Based on interview and record review the facility failed to ensure the resident had the right and the facility made prompt efforts to resolve resident grievances the resident may have for 1 of 4 residents (Resident #1) reviewed for grievances . The facility failed to follow their policy and procedure on Grievance/Complaints when Resident #1's family member voiced a concern on 02/19/26 to Human Resources regarding a concern about the oxygen tank not working when the resident was sent to a physician's appointments on 02/19/26 and concerned that the resident was not provided catheter care. This failure could place residents at risk of feeling their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings include:Record review of the Grievance Concern Report, dated 02/19/26, for Resident #1 revealed Patient representative had reported concerns to HR Manager T. Describe concern using factual terms: Family wanted to ensure Oxygen was full and foley had been cleaned. Family agreed to meet with IDT on 2/23/26 at 12:00 p.m. Documentation of facility follow-up: Family agreed to meet on 2/23/26 with HR, DON, Administrator, NP to review any/other concerns. Date assigned: Was left blank. Date to be resolved by: Was left blank. Was a group meeting held? Was left blank. What other action was taken to resolve concerns? (Specifics) Was left blank. Results of action taken: Was left blank. Plan care updated? Was left blank. Resolution of Concern: Was left blank. Executive Director's Signature: Was left blank. Typed statement attached to the Grievance Form was signed by the facility's Executive Director, dated 02/23/26, revealed, Meeting with Resident #1's family members. They wanted a follow up on oxygen portable tank and ensure it was properly working because they were informed at the appointment they were not sure the portable tank had air. They were informed tanks did not give the actual measure but staff were fully aware to pull the lower level to double-check it was full. They were informed all portable tanks were checked until 2/19/26 to include the tank was returned the same day. The family was grateful about the facility following to ensure all portable tanks were functioning properly in order to avoid or prevent any confusion in the future. They also needed to know about the foley being dirty and he was more ill, in the hospital and needed to know if it was because of the dirty foley. The Family was informed patient was in the facility for only 6 days and he was moved to the first hall at their request; family felt because the resident was confused and thinking he was still with the hospital and wanting to return to the facility. The Administrator had visited him that day and he was extremely confused and refusing care, wound care, ADL's, etc . When moved, he remained confused, but more at ease. They were informed Resident #1 came in from the hospital with 18 wounds and the NP stated he had lot of weight, very debilitated, refusing care and I even wanted him to be a DNR but left to the hospital. He also stated his lab work returned normal and no markers were identified. Family member said he was declining in the hospital and remembered he was the little troublemaker before he left to the hospital. Family asked for a smoking patch but resident was always anxious about smoking and always asking if he could go out and smoke. Family also stated Resident #1 felt he was at home and the nursing facility was his second home. They agreed with the meeting and said they would want him to return but had questions about his well-being; they also understood he returned to the facility confused and refused wound care, which was already a concern from his first admission. In conclusion to the meeting, the family was aware transporters had been trained in detail to ensure all areas of transportation. The nurses were aware to check the resident with transporters before they left. The foley catheter was clean when resident left and was bagged properly. Family agreed to notify the center of any updates. Document was signed by the facility's Executive Director .Record review of Resident #1's History & Physical, dated 3/30/26, revealed a [AGE] year old male. Resident #1 had diagnoses which included dry gangrene (right posterior calf right heel (the death of body tissue caused by a sudden or gradual loss of blood flow, left foot left posterior calf) wound VAC (is a device that uses gentle suction to help large or slow-healing wounds close faster) to RLE, dry gangrene to the RLE posterior calf heel and digits bilaterally, LLE (left lower extremity) dry gangrene to the left foot and ankle extending posterior laterally to the mid-calf, pulses not palpable, peripheral artery disease, history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), gastrostomy tube (a soft flexible tube placed through a small opening in the stomach directly into the stomach) dependent 3/04/26, foley Catheter in place, right tibial osteomyelitis (a painful bone infection caused by bacteria or fungi), aspiration pneumonia (a serious lung infection caused by breathing food. Liquid, saliva, or vomit down the windpipe instead of the food pipe), chronic kidney disease on HD (a long-term condition where kidneys gradually lose function, facility to filter waste from blood, often progressing slowly with few initial symptoms leading to end-stage renal failure requiring hemodialysis), tinea Cruris with fungal cellulitis of the groin (deep skin infection caused by fungi rather than usual bacteria) and perineal area, and acute respiratory failure (a sudden, life-threating condition where the lungs cannot properly exchange oxygen and carbon dioxide). Alert, oriented x 3. Code Status: Full Code. Record review of Resident #1's MDS , dated 04/15/26, revealed, Type of Record: Modify existing record. PPS 5-day Assessment. Entry Date: 04/14/26. Reentry from acute hospital. Active Diagnoses: PVD (circulation problem where narrowed or blocked blood vessels outside your heart and brain reduce blood flow to your limbs and organs due to plaque buildup), Renal Failure, Pneumonia , Wound Infection, COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), Respiratory Failure, Gangrene, Gastrostomy, Feeding tube, Skin Tears, and continuous oxygen therapy. Record review of Resident #1's Care Plan, dated 04/14/26, revealed:-Patient has catheter. Interventions: Change foley catheter as ordered. Indwelling catheter care as ordered and as needed. Monitor urine odor, color, clarity and amount as needed.-I am at risk related to respiratory conditions and/or deficiencies/abnormalities in pulmonary function. Interventions: Administer oxygen as ordered. Keep HOB elevated. Monitor breath sounds as needed. Monitor for shortness of breath. -Full Code. Interventions: Staff will follow through with my wishes and implement resuscitation, when I am in need of drastic measures to facilitate breathing. Record review of Resident #1's admission Record, dated 5/29/26 , revealed an original admission date of 10/22/25 and re-admission date of 4/14/2026. The Resident expired at the facility on 04/15/26.During an interview on 05/29/26 at 10:42 a.m. with the Executive Director, he denied receiving a text message from the resident's family member requesting a meeting to discuss some concerns related to the care and services provided at the facility. He said the DON was the one who received the text message from the family member. He said the DON sent him a copy of the text message and would provide a copy of the screen shot as requested. He said he called the family member to follow up on her new concerns, and the family member refused to talk to him and asked him to speak to Human Resources T and never said why they wanted to speak to HR. He said, I am responsible for addressing Grievances and completing the Grievance Forms. He said he had not documented in the resident's medical record when he called the family member to schedule a meeting at the family's request. He said he could not remember why they had not held the meeting with the family member as requested. He said they had not completed a Grievance Form when the family member called to report she had concerns about the care and services that were provided to Resident #1 at the facility. He said, I know that we should have completed a Grievance Form according to our facility policy. During an interview on 05/29/26 at 11:28 a.m. with RN ADON, she said she was not aware if the family voiced any concerns about the care that was provided to the resident.During a telephone interview on 05/29/26 at 12:21 p.m. family member said they wanted justice for the resident . It was reported Resident #1 was discharged from the hospital with a diagnosis of sepsis (life threatening reaction your body has when it overreacts to an infection) related to wounds . It was reported the resident arrived at the facility on 04/14/26 and expired on 04/15/26 at the nursing facility. The family member said the night nurse had not checked resident. The family member said when CPR was done at the nursing home, the nurse suctioned 100 ml of fluid. The family member said they asked the DON to please go to assess the resident at the hospital prior to him being sent to the facility. She said the DON told them the resident looked great and the resident spoke to her. The family member reported the resident's family member was very concerned because the resident could not talk when he was sent to the nursing facility from the hospital. The family member said she sent a text message to the Administrator asking him to call her to talk about the concerns she had about the resident, and he never responded. The family member said she deleted the text message that was sent to the Administrator from her cell phone. The family member said the DON promised her the Administrator and HR would meet with her, but they never called back to talk about the concerns she had about the resident. She said the DON told her the resident would be placed in a room by the nurses station so they could check on him. The family member said on the day the resident expired, the nurse who was assigned to him was on lunch break. The family member said the resident had not been checked as DON had said they would. The family member also reported the resident was sent to an appointment, and she was informed by the physician's office staff the oxygen tank was not working, and the resident was not getting his oxygen as ordered. The family member said the doctor's office staff called 911 and the resident was sent to the hospital. The family member reported when the resident arrived at the hospital the resident's penis was full of crusted drainage. The family member said she called the facility to report her concern to the Administrator and Human Resources, and they scheduled a meeting on 04/29/26. The family member said when she went to the nursing facility on 04/29/26 at 12 noon, for the scheduled meeting with the DON, the Administrator and Human Resources she was informed the meeting could not be done as scheduled because the Administrator was not at the facility. The family member said the Administrator never called back to reschedule the meeting. During an interview on 05/29/26 at 4:00 p.m., with the Executive Director and Human Resources T revealed a family member called the facility on 02/19/26 to request a meeting with the Executive Director and HR to discuss some concerns about the care that was being provided for the Resident #1. The Executive Director said he, the DON and HR met with the family member on 02/23/26 to discuss concerns about the oxygen tank not having oxygen when Resident #1 was sent to an appointment and could not remember the date and the family had also reported the foley had not been cleaned on that da y. He said the resident was sent to the hospital from the doctor's office on that day and did not know why. He said he informed the family member all the facility's portable oxygen tanks were checked on 02/19/26 by the Maintenance Director, that included the portable oxygen tank Resident #1 took to his doctor's appointment on that day and no issues were identified. He said he did not know if the Maintenance Director had any documentation of when he checked the portable oxygen tanks on that day . He said the family was grateful for the facility following up to ensure all portable oxygen tanks were functioning properly. He said the family member had also reported the resident's catheter was dirty when he had arrived at the hospital and needed to know if that was what had caused the resident to get sick and had been the reason for hospitalization. He said, I think nursing had checked the catheter and there were no concerns. He said the facility's transporters were trained in detail to ensure all areas of transportation were covered and were instructed to have the nurse check the resident before they left the facility. He said the nurse reported the resident's catheter was clean when the resident left the facility to go to the physician's office on 02/19/26. He said they had not documented in the resident's clinical record they had met with the family on 02/23/26. He said the portable oxygen tank did not give the actual oxygen contents. He said the portable oxygen tanks only had a gauge that showed green if the tank had oxygen or red if the tank was empty. He said the resident was moved to the first floor at the family's request and could not remember why the family had requested the move. He said the resident was confused. He said the resident was readmitted from the hospital with eighteen wounds and he suggested to the family to make the resident a DNR. He said he could not recall when they scheduled the second meeting with the resident's family and could not remember why the meeting was not held as scheduled . During an interview on 06/01/26 at 10:30 a.m., Maintenance Director B said he checked all the portable liquid oxygen tanks on 02/19/26 when he was informed Resident #1's family member reported the resident was sent to an appointment and the portable oxygen tank was not working. He said he had not found any portable oxygen tanks that were not working properly. He said he did not have any documentation that he had checked the portable oxygen tanks on 02/19/26 . During an interview on 06/01/26 at 11:49 a.m. with the DON, she said she was aware the family had some concerns but could not remember what they were. She said, The only time I became aware of any family concerns was when we met the family on 02/19/26 and the Administrator completed the Grievance Form. During an interview on 06/02/26 at 9:58 a.m., Human Resources T said she remembered when a family member called on 02/19/26 asking to have a meeting with her, the Administrator and the DON and had voiced two concerns related to sending the resident to an appointment with an empty oxygen tank and a concern about the resident's catheter. She said, I wrote down her concerns and gave the piece of paper to the Executive Director. I do not remember that date that I handed the note to the Executive Director . She said she did not know why the resident's family member wanted her to be present at the meeting because she was only involved with issues that were related to the staff. She said she was not aware the family member had called again to request another meeting to discuss concerns about the care provided to the resident .During a telephone interview on 06/02/26 at 11:05 a.m. with CNA Q she had not been provided with any training at the facility on how to check the portable liquid oxygen tanks. She said, she learned how to read the gauge on the portable liquid oxygen tanks at her previous employment. She said, You hold the shoulder strap closest to the gauge on the tank and slightly tilt it downward to see if the gauge moves to the green area which indicated there was oxygen in the portable oxygen tank. She said she was trained on how to give catheter care to a male resident approximately 6-9 months ago. She said she occasionally found residents with crusted drainage on the penis. She said she had not reported this to the nurse, due to fear of retaliation . Record review of the facility's Grievance Policy and Procedure, revised 02/08/2021, provided by the Executive Director on 06/01/26 at 6:20 p.m. revealed: Purpose: To ensure all patients, legal representatives/responsible parties, staff and visitors are aware of the facility's grievance procedure. Policy: Each patient's legal representative and his/her responsible parties, family members, staff, and visitors have the right to voice complaints and/or grievances without discrimination or fear of reprisal. Such grievances include those with respect to care, treatment, or other matters relating to quality of care or quality of life. Grievances can be communicated to a staff member either verbally or in writing. The facility will make every effort to promptly investigate and resolve any grievances . Responsible Areas: All Staff. Procedure: All grievance should be given to the Executive Director or Designee. All patients, legal representatives and/or responsible parties are provided with information concerning his/her right to voice grievance either in writing or verbally. All patients will be informed of the location of the facilities grievance forms should they wish to write a formal complaint. Any patient who wishes to do so may express his/her grievances in writing or verbally to any staff member; However, they are strongly encouraged to express the complaint(s) directly to the Social Services, Executive Director or the Manager on Duty. If the complaint is verbal, it is the responsibility of the staff member who received the complaint to properly complete the grievance form on behalf of the complainant. The complaint form must be provided to the Executive Director or Designee immediately. The agreements will be given to the appropriate department manager for follow up and resolution. All grievances will be reviewed in morning meeting with IDT members. Department managers are responsible for resolution of all complaints within his/her department. Department managers will note the disposition of the grievance in writing to the Executive Director or Designee as soon as possible, but no later than 72 hours of receipt. It is responsibility of the Department Manager in coordination with the Executive Director, when appropriate, to develop a process/plan for resolution of the grievance and notify the complainant about the plan of resolution. All actions taken on the grievance including meetings with the patient, telephone calls, action plans, revision of care plan, etc. must be documented on the grievance form. If the complainant or aggrieved part is dissatisfied with the findings and/or remedies, the Executive Director will make reasonable attempts to resolve the grievance. The Ombudsman will be notified if the grievance is not resolved, per patient/family representatives request .

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #2) reviewed for quality of care .The facility failed to ensure RN D wrote the verbal order given by the Nurse Practitioner on 05/08/26 for Resident #2 for a UA with Culture & Sensitivity. This failure could place residents at risk of delayed treatment/intervention and decline in health. Findings include:Record review of Resident #2's admission MDS, dated [DATE], revealed a BIMS Score 10 (cognitively impaired), occasionally incontinent of urine. Active Diagnoses: ESRD, and UTI in the last 30 days.Record review of Resident #2's Care Plan, dated 05/03/26, revealed the resident had incontinence of bowel & bladder. Record review of Resident #2's Daily Skilled Nurses Note, written by RN D at 3:06 p.m ., NP N in facility, new order for UA with C&S to be done.Record review of Resident #2's Daily Nursing Note, dated 05/11/26 at 9:45 a.m., written by LVN E, revealed NP N in facility rounding this AM at 8:00 a.m. NP N inquired about UA that was ordered on Friday 05/08/26 with RN D. This nurse was unable to find order for UA and no results were displayed. NP N made aware of findings, per NP N order UA with C&S today. Order placed pending UA collection. Record review of Resident #2's Daily Nursing Note, dated 05/11/26 at 2:53 p.m., written by LVN E, revealed Urine specimen collected via clean catch, sample placed if fridge pending lab pick up .Record review of Resident #2's History & Physical, dated 5/19/26, revealed an [AGE] year-old female who was re-admitted following an acute hospitalization for an acute exacerbation of chronic obstructive pulmonary disease and asthma, complicated by acute hypoxic respiratory failure, community acquired pneumonia, advanced dementia with agitation, and progression to end-stage renal disease. Record review of Resident #2's admission Record, dated 5/29/26 , revealed the original admission date was 12/24/25 and re-admission date was 05/19/2026. During an interview and record review on 05/29/26 at 4:19 a.m., RN ADON A said RN D had not written the Verbal Order on 05/08/26 that was given by NP N for a UA with C&S. She said according to the IDT note written on 05/11/26 by LVN E, revealed NP N was in the facility making rounds on 05/11/26 at 8:00 a.m. and inquired about the UA results that were ordered on 05/08/26. The NP stated he gave RN D a Verbal order for a UA with C&S on Friday 05/08/26 and RN D failed to enter the order in the resident's clinical record. ADON A denied knowing the order for the UA given on 05/08/26 was not carried out .During an interview on 06/01/26 at 12:40 p.m. with the DON revealed she had not been informed by LVN E on 05/11/26 that the UA with C&S had not been done on Resident #2 as ordered by NP N on 05/08/26 by RN D. She said the nurses were trained to immediately report to her or the ADON if labs were not done as ordered. She said the facility did not have a tracking system in place to track when labs were ordered and done according to physician's orders . She said the nurses entered the new lab order into the electronic records that alerted the Lab there were new orders pending to be completed. The DON said the NP would give verbal orders and the nurse was responsible for entering the verbal orders in the resident's electronic record to ensure physician's orders were carried out. She said the failure to write the verbal order for the UA for C&S on 05/08/26 placed the resident at risk of not receiving the necessary medical care to meet her needs . During an interview and record review on 06/01/26 at 1:05 p.m. with RN D, revealed she was given a verbal order from NP N for a UA with C&S on 05/08/26 for Resident #2 and had not entered the new order in the resident's electronic clinical record . She said she had not collected the urine because the resident said she did not feel she could urinate at the time she went to collect the urine sample. She said she offered the resident a straight catheterization (in -and-out catheterization to drain urine from the bladder) and the resident refused. She said she was going to try and collect the specimen the next day. She said she notified the on-coming nurse, LVN Y, that she had not been able to collect the urine sample but had not documented this in the resident's clinical record . She said, I think that I wrote this in the 24-Hour Report , but I am not sure. She said she had not notified the NP about not being able to collect the urine as ordered but had not documented the notification in the resident's electronic record. She said she was trained in nursing school to notify the physician or NP if unable to collect the urine sample as ordered. She said she was also trained to report to the DON and/or ADON if unable to collect urine for UA for C&S as ordered. She said she was not aware of the facility's policy on notifying the physician and/or NP if labs were not done as ordered. She said she was not aware of the facility's policy and procedure on Laboratory Services. She said the failure to write the verbal order for the UA for C&S on 05/08/26 placed the resident at risk of not receiving the necessary medical care to meet her needs.During a telephone interview on 06/01/26 at 1:43 p.m. with LVN E revealed she worked on 05/11/26 and was assigned to Resident #2 when NP N was making rounds and asked for the UA with C&S results that he had ordered on 05/08/26. She said she noted RN D had not written the order in the resident's electronic record on 05/08/26 and the UA with C&S had not been done as ordered. She said the nurses were trained to immediately notify the physician and/or NP if the nurse was not able to collect the urine sample as ordered and to document the notification in the resident's electronic clinical record. She said they also were trained to report to the DON and/or ADON if the nurse could not collect the urine specimen according to physician's orders. Telephone interview on 06/02/26 at 10:12 a.m., NP N said he had given a verbal order on 05/08/26 to the RN D who was assigned to Resident #2 for a UA with C&S. He said he had come to see Resident #2 on 05/11/26 and had inquired about the UA results for the UA with C&S that had been given on 05/08/26 and was informed by LVN E who was assigned to Resident #2 on 05/11/26 that the lab order he had given on 05/08/26 for the UA C&S had not been written and had not been done as ordered. He said this placed the resident at risk of untreated UTI .Record review of the facility's policy and procedures on Laboratory Services, revised on April 2, 2024 , provided by the DON revealed: The facility shall provide or obtain laboratory services only when ordered by a physician; physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. File in the resident's clinical record signed and dated reports of ordered lab work.

Based on interview and record review, the facility failed to ensure that licensed nurses have specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessment for 1 of 6 residents (Resident #1) reviewed for nursing services.-The facility failed to ensure on 03/06/2026 that LVN A did not practice outside her scope of practice when she removed a PICC Line for Resident #1 when this needed to be completed by an RN, per Texas Board of Nursing standards. This failure placed the resident at risk for potential harm by nursing staff providing care outside of their scope of practice.The findings include:Record review of Resident #1's face sheet dated 3/20/2026 revealed a [AGE] year-old male with an original admission date on 4/28/2022 and a readmission date on 2/10/2026. Record review of Resident #1's MDS assessment dated [DATE] revealed the resident had a BIMS score of 11 with the significance being moderate cognitive impairment. Resident #1 was coded for diagnoses of atrial fibrillation (condition of rapid, irregular heartbeat), heart failure (a condition where the heart cannot pump enough blood to [NAME] the body's needs), pulmonary thrombo-embolism (life threatening blockage in a lung artery usually caused by blood clot), and had a pacemaker in pace.Record review of Resident #1's care plan dated 2/12/2026 revealed the resident had a focus of completing an antibiotic regimen via PICC line with a revision/completion date on 3/2/2026. Record review of Resident #1's physical and history dated 2/10/2026 revealed the resident had diagnosis of chronic systolic congestive heart failure (long term condition where the left ventricle weakens , reducing blood flow), chronic atrial fibrillation (a sustained heart arrhythmia where upper chambers quiver), ischemic cardiomyopathy with pacemaker (severe weakening of the heart muscle caused by plaque buildup or a heart attack), venous insufficiency (occurs when leg vein calves become weak or damaged and fail to return blood to the heart).Record review of the complaint allegation read in part, on 03/06/2026 [LVN A] removed the Peripherally Inserted Central Catheter (PICC LINE), from [Resident #1]. The complainant believes she is not supposed to remove the PICC Line without expressed permission or supervision from a Registered Nurse.Record review of Resident #1's progress notes dated 3/6/2026 at 6:19 PM completed by LVN A on Resident #1's profile read in part, patients midline discontinued per MD order using aseptic technique, measured at 10cm, tip intact and clean. Pressure applied 5 minutes, no active bleeding noted. Pressure dressing applied and patient made aware dressing can be removed in 3-4 hours. Tolerated procedure well. Patient resting comfortably in bed all safety measures in place, call light in reach.During an interview and observation on 3/20/2026 at 11:41 AM with Resident #1, he stated that he had been at the facility for a month. He stated he had a PICC line and it was removed while he was in the facility a couple weeks ago. He revealed a plastic cover inserted on his left tricep. He stated he did not remember who was in the room when the PICC line was removed. He stated he did not experience any pain or discomfort during the procedure. He stated he did not experience any pain discomfort or symptoms the days following. He denied feeling pain or discomfort on the extraction site during the interview. Observation of the PICC line extraction site showed no swelling, signs of infection, redness, or scabbing.During an interview on 3/20/2026 at 12:39 PM with LVN A, she stated she had worked at the center for a year and as an LVN for 16 years. She stated some of her responsibilities were to start intravenous lines, provide ADL care, provide wound care, complete admissions/discharges, and administer medication. She stated that PICC lines LVNs were only allowed to change the bandage dressing. She stated LVNs did not remove PICC lines. She stated it was not within their scope of practice to remove PICC lines. She stated that the RNs were responsible for pulling PICC lines. She stated that PICC line removal required an order from the provider. She stated the last in-service she received for clinical skills, was last year. She stated it affected residents if the LVN removed a PICC line, because there could be complications that were out of the LVNs' skills and scope of practice. In a follow-up interview at 2:29 PM, she stated she removed the PICC from Resident #1 and estimated it was a couple of weeks prior. She stated it was brought to her attention by the ADON and DON, and was notified that was not allowed by the Texas Board of Nursing regulations. She stated she was the only employee in the room and no other employee RN oversaw the process. She stated the resident was not affected by bruising, swelling, or discomfort/pain during the process. She stated there was no change in condition in Resident #1. She stated she had an informal conversation via text with the DON, and did not receive an in service/training for the incident. She stated the facility had not taken any action against her for removing the PICC line and added the nursing supervisors and administrator were aware for 2 weeks. She stated it affected residents if staff practiced out of their scope of practices drastically with problems of continuous bleeding, blood clots, hematomas.During an interview on 3/20/2026 at 1:05 PM, she stated, as an RN, she could perform TPN care, PEG tube, and assist with anything the LVNs and CNAs needed. She stated she did assist with PICC line care for antibiotics administration. She stated, per facility policy, only an RN can remove a PICC line with provider orders. She stated that the line was more invasive and ran from the arm veins to the general heart area. She stated it affected the residents because there could be significant pressure applied to the cite, ensure the site was fine, and the catheter was fine, and some bleeding would be present. She stated she had never removed PICC line in the facility. She stated it was out of the scope of practice for LVNs to be removing PICC lines. She stated the last in services for skills, competencies, and scope of practice was during orientation a year ago.During a phone interview on 3/20/2026 at 1:29 PM with the NP, he stated he provided orders to remove the PICC line, and would have expected an RN to complete the removal. He stated he would prefer an RN to complete the removal over an LVN. He stated there was no change of condition reported to him following the order for removal. He stated he was not aware of the scope of practice for an LVN, but was aware it was within the scope of practice for an RN to remove a PICC line. He stated that he had no concerns with the nurses at the facility and was made aware of all change in conditions promptly. During an interview on 3/20/2026 at 2:40 PM with the ADON, she stated that LVNs oversaw resident care and were supervised by RNs. She stated that an RN needed to be present with an LVN for removing a PICC line. She stated that LVNs were not allowed to remove a PICC line per the Texas Board of Nursing, the procedure needed further evaluation and monitoring by an RN due to the potential risks a resident could experience. She stated that there was a risk of the catheter breaking, infection, embolism (life threatening blockage of the blood vessel) and was considered care beyond the scope of practice for an LVN. She stated she was aware of an incident that LVN A removed the PICC line on Resident #1 under the discontinue orders for by the NP. She stated she was made aware of the incident on 3/9/2026 (next business day) during audits of progress notes. She stated she messaged LVN A and notified the DON immediately. She stated Resident #1 had already discontinued antibiotics that were administered via the PICC line. She stated she followed up with Resident #1, and he did not appear in distress, discomfort, affected by a change of condition, and did not voice any complaints/concerns about the procedure of removal. She stated she reported it to her DON, and added she had the power to enact a corrective measure before 3/20/2026. She stated it affected residents if LVN practiced outside of their scope of practice because there could be additional issues that an LVN might not possess the knowledge on how to handle a situation, and what signs or symptoms to look out for. During an interview on 3/20/2026 at 3:04 PM with the DON, she stated she was made aware Resident #1 had his PICC line removed by LVN A on 3/9/26. She stated she notified LVN A about her scope of practice and referred her to the policies on the Texas Board of Nursing page on LVNs scope of practice for PICC lines. She stated that there was supposed to be a 1:1 in-service with the ADON and LVN A. She stated she appointed her ADON to complete the 1:1 the week of the March 9th. She stated she did not follow up to see if it was completed because she forgot due to obligations and working the floor. She stated she notified LVN A she could not be pulling PICC lines via text on 3/9 and in-person on 3/9. She stated she was not referred to the board of nursing or suspended. She stated there were no concerns, symptoms, or reports from Resident #1 regarding the procedure. She stated it could cause harm to the residents if LVNs were completing tasks outside of their scope of practice. She stated there was potential harm for not checking to see if the catheter was intact post-removal. She stated the last in-service for nursing competency check without a return demonstration was in 2025.During an interview on 3/20/2026 at 4:11 PM with the Administrator, he stated that he was aware that LVN A removed the PICC line from Resident #1 about a couple weeks ago. He stated his DON notified him. He stated that LVN A received in-servicing and education, but he was uncertain if it was 1:1 or facility-wide. He stated only RNs could remove the PICC line due to training and certification, and per the Texas Board of Nursing. He stated the resident was not affected, but there was the potential for harming the resident if LVN A was unaware what they were doing. He stated that Resident #1 did not complain about injuries or present a change in condition.Record review of the facility's 1:1 Education/In-service dated 3/13/2026 was addressed to LVN A by the Nursing Department and read in part, To clarify the Texas Boars of Nursing (BON) scope of practice regarding PICC lines removal and ensure safe, compliance care in the SNF setting.LVNs SHOULD NOT: Independently remove PICC lines, Make decision regarding central line removal, perform procedure without RN/provider oversight.Risks requiring RN-Level Care: Air embolism, catheter breakage, bleeding complications, infection risk. Acknowledgement: I understand that PICC line removal is outside my independent LVN scope in Texas and requires RN involvement. The 1:1 document was signed by LVN A on 3/20/2026 and explained by the ADON.Record review completed on 3/20/2026 of the webpage titled Practice - Texas Board of Nursing Position Statements under section 15.3 titled LVNs Engaging in IV Therapy, Venipuncture, or PICC lines read in part, .The Board has further determined that vocational nursing programs do not provide the LVN with the educational foundation to assure client safety in insertion and removal of Peripherally Inserted Central Catheters (PICC lines) or midline catheters, inclusive of vein selection, insertion/advancement/retraction of the catheter, determining placement, and monitoring of the client for untoward reactions in relation to catheter insertion and removal.It is the Board's position that insertion and removal of PICC lines or midlines catheters is beyond the scope of practice for LVNs.

Based on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for physician notification of changes. LVN A failed to immediately notify Resident #1's physician when Resident #1 showed a change in condition (blood in urine) on 08/01/2025. These failures could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status.The findings included:Record review of Resident #1's admission record dated 11/24/2025 revealed an 89 y/o male, with an admission date of 06/17/2025 and a readmission date of 09/09/2025. Record review of Resident #1's History and Physical dated 10/08/25 revealed diagnoses of urinary retention, and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland). Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 12 indicating moderate cognitive impairment. Record review of Resident #1's care plan revised on 10/27/2025 revealed Resident #1 had a catheter related to Benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland)/Urine retention. Interventions included monitoring urine, color, and amount as needed. Record review of Resident#1's progress notes section in the facility's PCC system reflected an entry dated 08/01/25 at 5:17 a.m. by LVN A that stated CNA reported to this nurse patient output only 25mls for the shift. This nurse noted red tinged urine in drain bag. This nurse attempted to adjust indwelling catheter and patient refused, stated he is doing ok. Will notify oncoming shift. Record review of Resident #1's progress notes section in the facility's PCC system reflected an entry dated 08/01/2025 at 4:03 p.m. by LVN B that stated Family member expressed concern that patient had very little drainage in foley bag with clots in tubing. Changed foley catheter, had light blood-tinged urine draining, then drainage became dark red. Notified MD/NP, ordered US of bladder, noted. In an interview on 11/25/2025 at 10:21 a.m., RN C revealed that changes of condition included any changes in residents vital signs, falls and injuries. She stated that Resident #1 had a foley catheter, and that CNAs was responsible for monitoring output. She stated that if the CNAs was to notice any change in the urine such as blood, they was to notify the nurse. The nurse would then assess the resident, notate the color, amount of urine. The nurse should then notify the physician right away and the oncoming nurse. The risk of not notifying the physician in a timely manner was that it created a delay in care for the resident. She stated that the nurse is responsible to ensure that the physician is notified of any changes in condition for all residents under their care during their shift. In a telephone interview on 11/25/2025 at 12:02 p.m., LVN B revealed that she did not recall the incident on 08/01/25, but she remembered that Resident #1 would frequently pull at his foley catheter. She stated that red tinged urine was something that should be reported to the physician because it could be considered a change in condition. She stated that the nurse was responsible for ensuring changes in condition was reported promptly to the physician for resident safety and well-being. In a telephone interview on 11/25/2025 at 12:40 p.m., the DON revealed that Resident #1 had a foley catheter bag draining to gravity. She stated that reporting a change of condition depends on what the change of condition was, such as a change in the level of consciousness, and vital signs. She stated that blood in urine should have been reported to the physician by the night nurse that first noticed it and then followed up on it by the day shift nurse. She stated that it was important for a change of condition to be reported to the physician in a prompt manner because if it was not then it could affect the resident's health overall, and it was also important to know that interventions apply. She stated that it was the responsibility of the nurses to ensure that they report the change of condition to physician, oncoming shift and to charge nurse and to DON. She stated that she could not recall if the night nurse called the physician to report noted blood in urine. She stated that she had conducted an in-service for reporting change in conditions to the physician, but she could not recall when. In an interview on 11/25/2025 at 1:20 p.m., the Administrator revealed that Resident #1 did not like the foley catheter and would frequently pull at it. He stated that he was not aware of the incident on 08/01/25 of blood in urine. He stated that the expectations for the nurses were to notify the physician promptly of any changes of condition and for the nurses to follow the doctors' instructions and document everything done. He stated that the risk of not notifying the doctor promptly was a potential for a decline in residents medical condition. He stated that it was the responsibility of the floor nurses to ensure that they were reporting anything out of the ordinary to the doctor. He stated that the last in-service done on reporting changes of condition was on 08/2025. Record Review of change of condition in-service revealed training was completed on 08/06/2025 by facility DON. Review of facility policy titled Change of Condition reviewed on 04/02/2024 read in part . The nurse shall evaluate and document/ report the following:f) all active diagnosis The nursing staff will notify the physician if any of the above signs and symptoms are identified.

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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control in that:CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1.These deficient practices could place residents at risk for infection due to improper care practices.Findings included: Review of Resident #1's face sheet dated 10/30/25, revealed a 73- year- old female admitted to the facility on [DATE] with diagnoses including urinary tract infection (infection in any part of the urinary system), bacteremia (presence of bacteria in the blood), abdominal pain, malignant neoplasm of pancreas (pancreatic cancer), and muscle weakness. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required moderate assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was always incontinent with bowel and bladder. Review of Resident #1's Care Plan dated 10/14/25 revealed he had bowel and bladder incontinence. Its goal stated Resident #1 will have less episodes of incontinence through the review date. Observation of incontinence care for Resident #1 on 10/30/25 at 10:46 a.m. revealed CNA A did not wash her hands prior to donning gloves. She put on gloves in the hallway before entering Resident #1's room. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A again, did not wash her hands before exiting Resident #1's room. In an interview on 10/30/25 at 10:58 a.m. with CNA A, she stated she should have washed her hands before starting care and changed her gloves during care. CNA A also said she should have changed her gloves before retrieving a clean brief and placing them underneath Resident #1. CNA A stated she has been in the facility for 4 years and received infection control training about 6 months ago. She said she was not paying attention, that was the reason for not changing her gloves. CNA A added the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 10/30/25 at 3:30 p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the staff to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. She explained the employees receive infection control training annually and periodically monitor staff with return demonstrations in providing care. The DON stated she was responsible for the infection control prevention for the facility. Review of the facility's Handwashing and Hand hygiene policy revised March 14, 2024, reflected the following:PURPOSE:Perineal care, also known as peri-care, involves cleaning the private areas of apatient. This practice is common in bedridden patients and those with incontinence.Since the perineal region is prone to infection, patients with these conditions mustreceive peri-care daily and as needed.Personnel involved: Licensed Nurses and CNASPROCEDURE:1. Introduce self to patients and explain what you will be doing2. Gather supplies needed.3. Provide privacy.4. Wash hands and apply gloves.5. Ask patients to lay on their backs and open their legs.6. Cleanse perineum, using front to back motions. Use freshwash cloth/ wipes for each pass from back to front.7. Never wash back to prevent as this causes contaminationand can cause infection.8. Change gloves in between cares and as needed.9. Dispose of soiled gloves and perform handwashing.

Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 2 (Resident #3 and Resident #155) of 12 residents reviewed for medication storage , in that: Resident #3 had a clear measuring cup at bedside with Zinc Oxide pomade (skin ointment) and a tongue depressor in it, exposed and within reach of other residents. Resident #155 had a clear measuring cup with unknown pink ointment at bedside, exposed and within reach of other residents. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Resident # 3 Record review of Resident #3's Face sheet dated 6/17/25 revealed an [AGE] year-old female with an original admission date of 8/8/24 and a readmission date of 4/18/25. Record review of Resident #3's health and physical dated 8/26/24 revealed an [AGE] year-old female with a diagnosis of pressure ulcer of sacral region (the area of the lower back and pelvis that overlies the sacrum which is a large, triangular-shaped bone located at the very bottom of the spine, just above the tailbone or coccyx) and unspecified constipation. Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS (brief interview for mental status) score of 14 indicating the resident was cognitively intact. It indicated in the active diagnoses section I, that Resident # 3 had a diagnosis of pressure ulcer of the sacral region. Resident #3 triggered the care area for arthritis. MDS revealed under section GG for Functional abilities that Resident # 3 was dependent on toileting hygiene, lower body dressing and putting on and taking off footwear and required substantial assistance with showering and upper body dressing. MDS revealed Resident # 3 was dependent on rolling on her bed to both sides. MDS revealed under section M for skin conditions and treatments that Resident #3 was at risk for developing pressure ulcers and required the application of ointments and medications. Record review of Resident #3's care plan dated 4/18/25 revealed the resident had a potential for pressure ulcers development related to scar tissue to sacral region and limited mobility. The care plan indicated Resident # 3 had moisture associated skin damage to the sacrum and gluts. The care plan called for intervention to follow the facility's protocols to prevent and treat skin breakdown by keeping the wound clean and dry by providing treatment to the site per physicians' orders until healed. Resident #155 Record Review of Resident #155's admission record dated 6/19/2025 revealed a [AGE] year old female admitted to the facility on [DATE]. Record Review of Resident #155's history and physical dated 06/10/2025 revealed diagnosis of insulin-dependent diabetes mellitus, hypertension, hyperlipidemia(high cholesterol) and known left bundle branch block (a heart condition where the electrical signal that control the hearts rhythm is delayed or blocked). Record Review of Resident #155's admission MDS dated [DATE] revealed no BIMS score. Record Review of Resident # 155's care plan dated 06/11/2025 revealed resident had a potential for skin breakdown requiring barrier cream to be applied to affected area. Record Review of Resident #155's physicians orders dated 06/11/2025 revealed Barrier cream to coccyx/buttock/peri area/ redden area for prevention every and as needed every shift. In an observation and interview on 06/17/25 at 9:30 am revealed, a clear plastic measuring cup with an unknown pink cream like ointment was sitting on a nightstand in Resident #155's room. The resident did not know what the ointment was or what it was used for. The Residents family member stated that it had been sitting there for days, and he did not know what it was used for either. In an observation and interview on 06/17/25 at 10:43 AM, resident #3 was observed sitting in her bed. There was a clear measuring cup containing a white substance and a tongue depressor at her bedside on her nightstand. The resident stated that the substance was a medication pomade applied by staff to her coccyx area to help a wound heal. She believed staff had applied the medication earlier that morning and forgotten to dispose of it. The resident expressed that the cup should have been discarded after use because any remaining pomade would be unusable. In an interview on 06/18/25 at 01:38 PM with CNA A, stated that a nurse or an LVN would give the CNAs the cup with the cream for them to apply it to the resident. CNA A said if there was medication left on the cup, it needed to be disposed of, instead of leaving it on the residents' nightstand. CNA A explained that leaving the cream exposed could potentially contaminate the medication if dust or lint got into the cup. CNA A stated if the cream was to be reused and applied to the resident after being exposed and potentially contaminated, the wound on the resident could get infected, potentially making the resident sick. In an interview on 06/18/25 at 02:07 PM with LVN B, stated the orders with cream barriers or medications were to apply the medication and then dispose of any residual cream. LVN B said the cream in the container was zinc oxide and it was to be applied with the tongue depressor in the area ordered by the wound nurse and any residual medication should be disposed of. She stated the potential outcome was for the cream to be contaminated because it was left exposed to the air and if it was applied to a resident in a wound area, it could have a negative reaction and the wound could worsen and infected. She also explained if there was a possibility for a confused resident to ingest the cream by leaving it unattended at bedside, which would make them sick. In an interview on 06/19/2025 at 11:30am with RN D, revealed that medications were not to be left at bedside unattended for any resident. She stated that leaving medication unattended could potentially expose the resident to misuse of the medication such as medication not being applied to the indicated area. She stated that it was an infection control issue because it was exposed to air. She could not recall the last training done about not leaving medications at bedside. She stated that it was the responsibility of the nurses to ensure that medications were not left at the bedside. In an interview on 06/19/2025 at 11:55am with CNA E, revealed that medications should not be left at bedside. She stated that as a CNA, the nurse would give them the cup with ointment that needed to be applied to the resident during a brief change or after a shower. She stated that after applying the ointment, the CNA would dispose of the cup immediately. Ointments should not have been left at bedside because residents could ingest it or apply it to contraindicated areas of the body. She could not recall the last training over not leaving medications at bedside. She stated that it was all staffs' responsibility to ensure that there weren't any medications left in the reach of residents. In an interview on 06/19/25 at 02:48PM with the Wound Care Nurse revealed that medications were not to be left unattended at bedside. She stated medication ointments were to be administered to the resident per physician's orders and disposed of per policy. She stated the risks of medications left unattended included residents misusing the medication. The Wound Care Nurse stated all nurses and medication aides were responsible for ensuring to administer all medications per physician's orders and to dispose of them properly. In an interview on 06/18/25 at 03:05 PM with the DON, she stated that the cream left on the residents' nightstand was zinc oxide which was a barrier cream to prevent rash and to promote wound healing. DON said the cream that was leftover in the cup should have been discarded immediately once the medication had been applied to the resident for infection prevention and control. The DON said there was a risk of infection for a resident if staff were to re-use the crem and it had been contaminated by being left exposed to the air. She explained that a potential outcome could be the wound would get infected, and the residents' health could deteriorate as a result of the infected wound. The DON concluded by saying that any medication that was open and administered to a resident needed to be discarded immediately and not be left by bedside. In an interview with the Administrator and the DON on 6/19/25 at 3:51 PM, it was revealed that the facility did not have a policy including information on procedures for supervising medications and the steps for disposing of a medication after it had been supervised.

Based on observation, interview and record review, the facility failed to provide ADL care for 2 of 16 residents (Resident # 152 and #206) reviewed for ADLs. The facility failed to ensure Resident #152 and #206's fingernails were clean and free from debris. This failure could place residents who required assistance with ADL's at risk for unmet care needs. Findings included: Resident # 206 Record review of Resident #206's face sheet dated 06/19/25 revealed resident was an [AGE] year-old female with an initial admission date 05/21/25. Record review of Resident #206's health and physical dated revealed medical diagnosesis of Diabetes Mellitus, hypertension (high blood pressure), anxiety, depression, and Alzheimer's disease (a neurodegenerative disease affecting memory and ability to perform activities of daily living). Record review of Resident #206's admission MDS dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. Section GG-Functional Abilities notated Resident #206 required substantial/maximal assistance and was dependent, meaning the helper does more than half or all the effort to complete activities. Record review of Resident #206 care plan revealed resident had an actual/potential decline in resident's ability to perform her activities of daily living and called for staff to provide assistance as needed with grooming, bathing, and personal hygiene. In an observation 06/17/25 at 10:19 AM revealed Resident #206 had dirty fingernails, with black debri under fingernails on both hands. In an interview on 06/19/25 at 12:32 PM with the ADON revealed nursing staff were responsible for monitoring resident's nails. She stated CNA's were to clean the residents' fingernails and nurses were to file or cut them. She stated the risks of not maintaining clean, groomed nails were injuries such as cuts on the skin, or an infection control issue. In an interview on 06/19/25 at 01:42 PM with the DON, she stated the facility provided grooming services including fingernail cleanliness and trimming. She stated the nursing staff such as CNA's and the nurses were to cut and clean the nails. The DON stated no one monitors to ensure this service was provided. The DON stated the risks of untrimmed and dirty nails including an infection control issue. In an interview on 06/19/25 at 2:05 PM with the Administrator revealed that the facility provided fingernail trimming and cleaning services to residents. She stated that if residents were diabetic, nurses were to provide nail care and if not diabetic, then all staff could provide nail care. She stated that the nurse was responsible for monitoring residents' fingernails. She stated that she believes nail care was reviewed under ADL training upon hire and annually. She stated that the risk of residents having long dirty fingernails would be that if residents put fingers to mouth while eating something it could have led to infection. Resident #152 Record Review of Resident # 152's admission Record dated 06/19/25 revealed a [AGE] year-old male with an original admission date of 11/29/2022 and a readmission date of 05/20/2025. Record Review of Resident # 152's History and Physical dated 06/18/25 revealed medical diagnoses of Dementia (a neurodegenerative disease a group of symptoms affecting memory, thinking and social abilities), muscle weakness, type 2 Diabetes, depression, and anxiety. Record Review of Resident #152's admission MDS dated [DATE] revealed a BIMS score of 04 indicating severe cognitive impairment. Section GG-Functional Abilities notated Resident #152 required substantial/maximal assistance with personal hygiene, meaning the helper does all the effort while the resident does none of the effort to complete the activity. Record Review of Resident #152's Care Plan revealed the resident was diagnosed with depression and called for staff to monitor for signs or symptoms of depression. In an observation and interview on 06/17/25 at 9:37 AM in residents room, it was revealed Resident #152 had long dirty fingernails for both hands. He stated that he would have liked his fingernails to be cleaned and cut. In an interview on 06/19/25 at 2:05 PM with the Administrator revealed that the facility provided fingernail trimming and cleaning services to residents. She stated that if residents were diabetic, nurses were to provide nail care and if not diabetic, then all staff could provide nail care. She stated that the nurse was responsible for monitoring residents' fingernails. She stated that she believes nail care was reviewed under ADL training upon hire and annually. She stated that the risk of residents having long dirty fingernails would be that if residents put fingers to mouth while eating something it could have led to infection. Review of facility policy titled ADL Services dated 02/01/16 read in part Patients shall receive assistance with activities of daily living (ADLs) every shift, as appropriate including grooming.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident # 3, Resident # 38, Resident # 104) of 12 residents reviewed for accommodation of needs. The facility failed to ensure Residents 3, 38 and 104, had their call lights within reach. These failures could place residents at risk for not having their needs/preferences met. Findings included: Resident #3 Record review of Resident #3's Face sheet dated 6/17/25 revealed an [AGE] year-old female with an initial admission date of 8/8/24 and a readmission date of 4/18/25. Record review of Resident #3's health and physical dated 8/26/24 revealed an [AGE] year-old female with a diagnoses of generalized muscle weakness, lack of coordination, abnormalities of gait and mobility, unspecified gout (a painful and common form of inflammatory arthritis), and age-related physical debility. Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. It indicated in the active diagnoses section I, that Resident # 3 had triggered the care area for arthritis. MDS revealed under section GG for Functional abilities that Resident # 3 had limited range of motion with impairment on both sides of upper extremities, was dependent for toileting hygiene, lower body dressing and to putting on and taking off footwear and required substantial assistance with showering and upper body dressing. The MDS revealed Resident # 3 was dependent on staff for rolling on her bed to both sides and required substantial assistance for sitting to lying and lying to siting positions, and from siting to standing. Record review of Resident #3's care plan dated 4/18/25 called for interventions that included making sure the residents' call light was within reach and encouraging the resident to use it for assistance as needed. Resident #38 Record review of Resident #38's face sheet dated 06/19/25 revealed a [AGE] year-old male with initial admission [DATE] and readmission date 05/24/25. Record review of Resident #38's health and physical dated 06/18/25 revealed a medical diagnoses of dysphagia (difficulty swallowing), Cerebrovascular accident (Stroke), memory and attention deficit, delirium (a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes), malnutrition, lack of coordination, and impaired mobility. Record review of Resident #38's significant change of status MDS dated [DATE] revealed a BIMS score of 2, indicating severe cognitive status. In Section GG-Functional Abilities revealed Resident #38 was dependent for all self-care abilities, meaning the helper does all of the effort, and the resident does none of the effort to complete the activity. Record review of Resident #38's care plan revealed resident was to be monitored for fall risk. In an observation and interview on 06/17/25 at 2:21 PM with Resident #38 was in his wheelchair and the call light was observed on the resident's bed frame on the opposite side where resident was. CNA G stated Resident #38 was unable to move by himself in his wheelchair and the call light was out of the resident's reach. She stated the risk of Resident #38 not having his call light within reach included injury or a fall. In an interview on 06/19/25 at 11:30 AM with RN H, she stated the purpose of the call light was for residents to request assistance from staff. She stated the call light was to be located within the resident's reach, whether the resident was in their bed or wheelchair. RN H stated nursing staff were responsible for monitoring call light placement. RN H stated nursing staff round on residents every 2 hours and the ADON rounds on residents' multiple times throughout their shift. RN H stated the risks of a call light being out of residents' reach included a fall or not having needs met. In an interview on 06/19/25 at 11:55 AM with CNA E revealed residents use call lights to communicate or request attention from staff. CNA E stated call lights were to be within the resident's reach and the risks of call lights not being in reach included injury or not having needs met. She stated that the nurses and CNA's were responsible for monitoring call lights. She stated the administration and supervisors also rounded on residents daily and included call light placement. In an interview on 06/19/25 at 12:29 PM with the ADON, she stated residents use their call light to request assistance from staff. She stated the call light was to be within the residents' reach. She stated every staff member was responsible for ensuring the call light was within residents' reach. The ADON stated nursing staff round on residents every 2 hours including call light placement. She stated the risks of call lights being out of reach included injury or a fall. Resident #104 Record review of Resident #104's Face sheet dated 6/17/25 revealed a [AGE] year-old male with an admission date of 5/23/25. Record review of Resident #104's health and physical dated 4/30/25 revealed [AGE] year-old male with a diagnoses of abnormalities of gait and mobility, muscle wasting and atrophy (refers to the decrease in size and mass of muscle tissue), lack of coordination and generalized muscle weakness. Record review of Resident #104's admission MDS dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. The MDS indicated under section GG for functional abilities that Resident # 104 had limited range of motion with impairment to both sides on lower extremities. Resident # 104 was dependent on staff for eating, oral hygiene, toileting hygiene, shower and lower body dressing. Resident # 104 depended on personnel for rolling to both sides while on bed, sit to lying and lying to sitting on side of the bed, sit to stand, transferring from bed to wheelchair and toilet transfer. Record review of Resident #104's care plan dated 5/23/25 revealed Resident # 104 was at fall risk related to impaired mobility secondary to weakness and debility. The care plan indicated interventions by always keeping the call light within reach, to post signs on the residents' room with call don't fall to remind the resident to call for assistance. In an observation and interview on 06/17/25 at 10:17 AM, the resident #104 was lying in bed and greeted the surveyor. The call light was on the floor to the resident's right side and about three feet away from the bed. The resident stated he had not realized the call light had fallen to the floor and attempted to look at it, and stated he could not see it. The resident said that whenever the call light fell to the floor, he needed to wait until a staff member made rounds and went into his room and then he would request assistance if needed. The resident said if there was an emergency and the call light was not within reach; he would need to wait until a staff member went to check on him or he would try to shout for help and hope someone heard him. The resident said he was not able to get on his feet. In an observation and interview on 06/17/25 at 10:43 AM, resident #3 was sitting on her bed watching TV. The call light was observed on the floor near the back wall towards the head of the bed and out of the residents' reach. The resident stated that she needed assistance to get out of bed and to transfer to her wheelchair. The resident said she could not reach her call bell and was not able to see it. The resident stated that staff checked on her every hour and a half or up to two hours and said she would have to wait that amount of time if there was an emergency and she could not reach her call bell to ask for help. In an observation and interview on 06/17/25 at 2:21 PM with Resident #38 was in his wheelchair and the call light was observed on the resident's bed frame on the opposite side where resident was. CNA G stated Resident #38 was unable to move by himself in his wheelchair and the call light was out of the resident's reach. She stated the risk of Resident #38 not having his call light within reach included injury or a fall. In an interview on 06/18/25 at 01:46 PM with CNA A, stated the purpose of a call light was for the residents to call for assistance if they needed something. CNA A said the call light needed to be within a resident's reach and if it was not accessible for a resident, there was a risk of them trying to get up to look for it which could pose a fall risk in those residents who had been diagnosed for high fall risk, and for the residents not to get the help they needed on time. CNA A stated that staff made rounds every two hours to check on residents and to ensure the call lights were accessible for them. In an interview on 06/18/25 at 02:07 PM with LVN B, stated the residents needed to have access to a call light and it had to always be within reach. LVN B explained if a resident was not able to reach for their call light, it could potentially result in them not being helped in a timely manner which could result in several issues such as leaving a resident soiled or not responding to a serious emergency. In an interview on 06/18/25 at 03:05 PM with the DON, she stated the purpose of a call light was for residents to request assistance if they needed help. The DON said a call light needed to be within reach of all residents either clipped to the bed sheets near the residents' hand or on top of the bed if it was a touch pad with the call lights. The DON explained the risk of not having a call light within reach could result in accidents such as falls if they required assistance and a resident attempted to get up on their own and they were not able to transfer themselves. The DON stated all staff were responsible for checking on the residents while in their rooms to make sure they had their call light within reach. In an interview on 06/19/25 at 11:30 AM with RN H, she stated the purpose of the call light was for residents to request assistance from staff. She stated the call light was to be located within the resident's reach, whether the resident was in their bed or wheelchair. RN H stated nursing staff were responsible for monitoring call light placement. RN H stated nursing staff round on residents every 2 hours and the ADON rounds on residents' multiple times throughout their shift. RN H stated the risks of a call light being out of residents' reach included a fall or not having needs met. In an interview on 06/19/25 at 11:42 AM with the Administrator, she stated call lights were used by the residents so they could call the staff if they need assistance with something. The Administrator said the call light needs to be within reach of the residents and the potential risk if a call light was not within reach, was that a resident could not ask for help if they needed assistance with something or if there was an emergency and they needed help. The Administrator explained that staff such as CNAs, LVNs and RNs had to make rounds ensuring the call lights were always within reach of the residents. In an interview on 06/19/25 at 11:55 AM with CNA E revealed residents use call lights to communicate or request attention from staff. CNA E stated call lights were to be within the resident's reach and the risks of call lights not being in reach included injury or not having needs met. She stated that the nurses and CNA's were responsible for monitoring call lights. She stated the administration and supervisors also rounded on residents daily and included call light placement. In an interview on 06/19/25 at 12:29 PM with the ADON, she stated residents use their call light to request assistance from staff. She stated the call light was to be within the residents' reach. She stated every staff member was responsible for ensuring the call light was within residents' reach. The ADON stated nursing staff round on residents every 2 hours including call light placement. She stated the risks of call lights being out of reach included injury or a fall. Record review of the facility's Policy, not dated, titled: Call light policy, stated in part: When the resident is in bed or confined to a chair, be sure the call light is within easy reach to the resident.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to store foods in walk-in refrigerator and freezer in sealed containers. -The facility failed to label and date frozen pastries stored in the freezer. -The facility failed to keep container of tomato sauce free of dry drippings and residue around the lid. These failures could place residents at risk of food-borne illnesses. Findings included: Walk-in Refrigerator: -During an observation on 06/17/2025 at 8:10 am revealed the lids of 2 containers containing rice and rice and chicken soup to be slightly opened. - During an observation on 06/17/2025 at 8:12 am revealed a bag of carrots was torn, exposing the carrots to air. Walk-in Freezer: -During an observation on 06/17/2025 at 8:18 am revealed a bag of frozen turkey patties not properly sealed and exposed to air. -During an observation on 06/17/2025 at 8:19am revealed a container of frozen tomato sauce with dried drippings around the lid and running down the side of the container. -During an observation on 06/17/2025 at 8:20am revealed an undated bag of churros and donuts. In an interview with the Executive Chef on 06/19/2025 at 12:40pm revealed that all containers stored in the refrigerator and freezer should have been completely sealed to prevent any cross contamination and to preserve the freshness of the food items. He stated that all vegetables should have been kept in a sealed bag to prevent cross contamination and to seal in freshness. He stated that all containers should have been cleaned prior to being stored back in the freezer. He stated that staff were trained to ensure that all containers were cleaned after using them. He stated that dirty containers could have the potential for cross contamination and food could gather bacteria. He stated that all foods in the freezer should be in sealed bags to prevent freezer burn and prolong freshness and prevent cross contamination. He also stated that all foods should have been labeled and dated because if they were not labeled and dated, they could have expired, and the staff would not have known. He stated that all these things could lead to residents becoming sick by potentially having been exposed to bacteria or expired foods. In an interview with the cook on 06/19/2025 at 1:00pm revealed that all containers stored in the refrigerator were to be completely closed to prevent cross contamination and growth of bacteria. He stated that all vegetables were to be kept in sealed bags to preserve freshness and prevent bacteria growth. He stated that he was trained to ensure that all containers were cleaned upon storing them back in the refrigerator and freezer. He stated that this was to be done to prevent bacteria growth and cross contamination. He stated that all items in the freezer should have been dated so that the staff could know how long the food had been stored in the freezer. He stated not knowing how long food had been stored could have led to residents becoming sick due to eating something that was not fresh anymore. Review of facility policy titled Food Storage Policy dated 2021 read in part All frozen food items are to be properly sealed and dated. fresh fruits and vegetables should be placed in bins, cartons or bags to promote freshness.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #108) of 9 residents observed for oxygen management. The facility failed to post an Oxygen sign indicating Resident # 108 received oxygen. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Findings Include: Record review of Resident #108's Face sheet dated 6/18/25 revealed a [AGE] year-old female with an admission date of 6/3/25. Record review of Resident #108's admission MDS dated [DATE] revealed BIMS score of 13 indicating the resident was cognitively intact. The MDS revealed the resident was dependent on staff for toileting and personal hygiene, and required maximal assistance with showering, upper and lower body dressing and putting on or taking off footwear. Section I for active diagnosis in the MDS revealed Resident # 108 had asthma, chronic obstructive pulmonary disease, or chronic lung disease. Section J for health conditions revealed the resident had shortness of breath or trouble breathing with exertion and while lying flat. Section O for special treatment, procedures and programs revealed the resident was receiving oxygen therapy. Record review of Resident #108's care plan dated 6/18/25 revealed the resident used supplemental oxygen related to poor oxygen absorption and called for intervention to monitor for respiratory distress and to report to physician respirations, oximetry, increased heart rate, restlessness and headaches. The care plan stated Resident #108 had oxygen via nasal prongs at two liters continuously. In an observation and interview on 06/18/25 at 10:31 AM, the resident was in her room lying on her bed. She was wearing a nasal canula and was receiving oxygen. The resident stated she was in oxygen therapy, and she used her oxygen while she was inside her room. There was no oxygen sign posted outside the residents' room. In an interview on 06/18/25 at 01:46 PM with CNA A, she stated that when a resident was receiving oxygen in their room, an oxygen sign had to be posted by the door. This sign served to alert other staff to check oxygen levels and to warn visitors or anyone entering the facility about the potential fire hazard. She explained that failing to post a sign could lead to hazards and accidents for residents. In an interview on 06/18/25 at 02:07 PM with LVN B, she explained one of the reasons for posting an oxygen sign outside the resident's rooms was to alert anyone who went into the facility there was oxygen in use inside the room and to avoid potential fire hazards. LVN B stated the potential negative outcome for not posting an oxygen sign could result in fire hazards of residents not being checked for oxygen levels. In an interview on 06/18/25 at 03:05 PM with the DON, she stated all rooms who had oxygen in use inside in the facility were required to have an oxygen in use sign posted outside the door. The DON explained that a potential outcome for not posting a warning sign for oxygen in use outside a residents' room was that a resident could go without oxygen, and that a fire hazard and potential explosion existed. She also noted that ADONs were responsible for checking upstairs for oxygen signs, and it was an expectation for CNAs or LVNs to report to her or the administrator if they noted a room was missing an oxygen sign. In an interview on 06/19/25 at 11:42 AM with the Administrator, she expressed that oxygen signs were posted to notify staff and visitors of oxygen use in a room or by a resident. The administrator highlighted that there was a fire hazard if oxygen was in use without a sign posted outside the rooms and someone went in there and lit a spark. The Administrator stated there could also be a risk if a resident went unchecked for oxygen levels and they were in oxygen therapy. In an interview with the Administrator and the DON on 6/19/25 at 3:51 PM, it was revealed that the facility did not have a policy stating oxygen signs needed to be posted outside the rooms of those residents who received oxygen.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #213) of 10 residents reviewed for medications. The facility failed to administer Megestrol Acetate for Resident #213 per physician's order for 2 days. This failure could place the residents at risk of not receiving therapeutic doses of their medication. Findings included: Record review of Resident #216's face sheet dated 06/19/25 revealed resident was [AGE] year-old female with admission date 05/01/25 and her medical diagnoses: Nontraumatic intracerebral hemorrhage (type of stroke characterized by sudden bleeding into the brain tissue), Hemiplegia (paralysis that affects only one side of your body), Generalized Anxiety Disorder, muscle weakness, unspecified protein-calorie malnutrition, and Anorexia (treatable eating disorder in which people have a low body weight based on personal weight history). Record review of Resident #216's admission MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating resident was cognitively intact. Record review of Resident #216's health and physical dated 04/30/25 revealed active medication list included Megestrol Acetate, medication used to treat loss of appetite, by mouth daily. Record review of Resident #216's Medication Administration Record dated 05/01/2025 revealed Megestrol Acetate was not administered per physician order on 05/03/25, 05/04/25 and 05/05/25 . Record review of Resident #216's progress notes revealed no documented rationale for not administering medication per physician's order. In an interview on 6/19/2025 at 5:00 pm with RN F revealed that medication aids are the ones who administer most medications. She stated that when residents refuse medications or medications were not administered as per doctors orders, the med aide had to let the nurse know, the nurse would then go to resident and attempt to prompt them to take medication. If that did not work, then the refusal would have to be documented in a progress note and it would be reported to the doctor and to the ADON or DON. RN F stated nurses were responsible for monitoring medications aides administered medications or that medications were administered per physician's orders. In an interview on 6/19/2025 at 5:20pm with LVN B revealed that med aides administer the majority of medications. She stated that when there was a medication refusal, the medication aide was to let nurse know and then nurse would go prompt the resident to take the medication, if that did not work, then it would have been documented in a progress note and on the Medication Administration Record. She stated that the doctor would have been notified and the DON as well. She stated that documentation was nursing judgment, and she could not recall the last time there was training provided. In an interview on 06/19/2025 at 5:30 pm with the DON revealed that nursing staff was trained to document any medication refusals. She stated that medication aides have to let the nurse know when residents were refusing medications or not receiving medications as per physician's orders. She stated that the nurses would follow up with residents on the reasoning for their refusal of medications or review why they were not receiving medications per physician's orders and then document in a progress note. She stated that residents not receiving medications as per physician's orders could cause a decline in resident health depending on the medication and how long they were not receiving it. In an interview on 06/19/2025 at 5:40 pm with Administrator revealed that staff (nurses and medication aides) were to document any medication refusals or residents not getting medications as per doctors' orders. She stated that this was part of on-hire training and training as needed. She stated that she was not sure how long missing medication doses would affect the residents. Record review of facility policy titled Skilled Nursing Facility Policy: Nursing Documentation, not dated read in part Record daily nursing notes reflecting the residents' condition, responses to interventions and any changes in status.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #2's use of bed rails (enablers). The facility failed to implement a comprehensive person-centered care plan for CNA B not being able to work with Resident #2 due to an facility self-reported incident. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings include: Record review of Resident #2's hospital history and physical dated 11/22/24, revealed, an [AGE] year-old female diagnosed with anxiety and osteoporosis. Record review of Resident #2's face sheet dated 01/21/25, revealed, admission on 12/04/24 to the facility. Record review of Resident #2's order dated 12/04/24, revealed, Enablers - upper to allow use of bed controls and assist with bed mobility. Record review of Resident #2's Assistive Transfer Device Consent dated 12/04/24, revealed, Assistive Transfer Device: The facility utilizes fully functional beds that come equipped with transfer bars. The benefits of theses bars are - 1. Independent control of bed positions. 2. Assist with transferring and reposition. The risks are - 1. Falling. 2. Entrapment. It was signed by Patient/Guardian, nurse, and Patient #2. Record review of Resident #2's baseline care plan dated 12/04/24, revealed, there was no focus area for bed rail (enables) use. Record review of Resident #2's MDS dated [DATE], revealed, little to no cognitive impairment BIMS score of 13 to be able to recall or make daily decisions. ADLs were dependent (staff does all the work) for toileting, roll lift and right, and sit to lying while in bed. Patient #2 was not coded for bed rail (enabler) in Section P - Restraints and Alarms of the MDS. Record review of Patient #2's comprehensive care plan dated 01/21/25, revealed there was no focus area for bed rails (enablers). Record review of facility self-report dated 12/11/24, revealed during incontinent care on 12/10/24 Patient #2 hit her right wrist on a bed rail (enabler) when trying to assist CNA A who was being rough during incontinent care. LVN E noted Resident #2's right wrist to be swollen and tender to touch. CNA A was placed on suspension, the physician/DON/Administrator/family were notified, x-rays were ordered stat of Resident #2's wrist revealing no fractures, CNA A was not allowed to work with Resident #2 anymore, and facility self-reported to state agency. Facility summary of investigation revealed resident interviews were conducted with no findings in relation to occurrence. Facility investigation was unconfirmed. During an interview 01/17/25 at 2:04 PM, with the DON, she stated CNA A was conducting incontinent care when Resident #2 was trying to assist CNA A and Resident #2 hurt her herself and could not remember which hand it was. The DON stated x-rays were ordered stat and revealed no fractures. The DON stated CNA A was suspended until the facility investigation was complete and in-services on Abuse and Customer service were given to all the staff and CNA A. The DON stated CNA A was not to be assigned to Resident #2 and should have been care planned. The DON stated the risk was that the CNA A could end up assigned to Resident #2. The DON stated she had observed Resident #2's care plan and did not see any focus area or intervention for the bed rail (enabler) use. The DON stated there would be a risk of the patient getting hurt and nursing staff not knowing how to work with the resident. The DON stated all the nursing staff were responsible for the care plan. During an interview on 01/21/25 at 11:47 AM, with the MDS Coordinator and Administrator, the MDS Coordinator stated the MDS department and nurses were responsible for generating the care plans and making sure they were correct and accurate. The MDS Coordinator stated there was no focus area nor interventions on the care plan for Resident #2 for use of bed rails (enabler). The Administrator stated she did not see a focus area nor interventions for Resident #2 on the care plan. The MDS Coordinator stated it should have been care planned for CNA A to not be working with Resident #2. The MDS Coordinator stated the risk of not care planning it would be not identifying the issues and interventions related to the resident. During an interview on 01/21/25 at 1:38 PM, with NP, he stated that patients using bed rails (enabler) needed to have it care planned. The NP stated the risk of not having it care planned would depend on the situation of the patient.

Based on observation, interview, and record review the facility failed to assess the patient for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #2) of 4 patients reviewed for enablers (bed rails). Resident #2 did not have a Bed Transfer Bar Evaluation Assessment done to ensure the Enablers (bed rails) were appropriate for the use of Resident #2's needs. This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury. Findings included: Record review of Resident #2's face sheet dated 01/21/25, revealed, admission on 12/04/24 to the facility. Record review of Resident #2's hospital history and physical dated 11/22/24, revealed, an [AGE] year-old female diagnosed with anxiety and osteoporosis. Record review of Resident #2's MDS dated [DATE], revealed, little to no cognitive impairment BIMS score of 13 to be able to recall or make daily decisions. ADLs were dependent (staff does all the work) for toileting, roll lift and right, and sit to lying while in bed. Patient #2 was not coded for bed rail (enabler) in Section P - Restraints and Alarms of the MDS. Record review of Resident #2's order dated 12/04/24, revealed, Enablers - upper to allow use of bed controls and assist with bed mobility. Record review of Resident #2's baseline care plan dated 12/04/24, revealed, there was no focus area for bed rail (enables) use. Record review of Resident #2's comprehensive care plan dated 01/21/25, revealed there was no focus area for bed rails (enablers). Record review of Resident #2's Assistive Transfer Device Consent dated 12/04/24, revealed, Assistive Transfer Device: The facility utilizes fully functional beds that come equipped with transfer bars. The benefits of theses bars are - 1. Independent control of bed positions. 2. Assist with transferring and reposition. The risks are - 1. Falling. 2. Entrapment. It was signed by Patient/Guardian, nurse, and Patient #2. Record review of Resident #2's Progress Notes generated by LVN D dated 12/10/24, revealed, LVN D went into administrator morning medications when Resident #2 complained of pain to her right wrist. This LVN D attempted to reach over for blanket to further assess and Resident #2 yelled in pain and flinched without touching Resident #2. This LVN D then noted Resident #2 right wrist to be swollen and tender to touch. This LVN D asked Resident #2 how her wrist got hurt and Resident #2 stated it was during incontinence care where she hit her hand on the bar (bed rail (enabler)). X-ray were ordered for right wrist and medicated for pain. - 12/10/24 - Progress Note: X-rays results were negative for any fractures/dislocation to the right hand and wrist. Record review of facility self-report dated 12/11/24, revealed during incontinent care on 12/10/24 Resident #2 hit her right wrist on a bed rail (enabler) when trying to assist CNA A who was being rough during incontinent care. LVN E noted Resident #2's right wrist to be swollen and tender to touch. CNA A was placed on suspension, the physician/DON/Administrator/family were notified, x-rays were ordered stat of Resident #2's wrist revealing no fractures, and facility self-reported to state agency. Facility summary of investigation revealed patient interviews were conducted with no findings in relation to occurrence. Facility investigation was unconfirmed. During an interview on 01/21/25 at 11:05 AM, with the Administrator, she stated she was not able to see or find a Bed/Transfer/Bar Evaluation for Resident #2. During an interview on 01/21/25 at 1:38 PM, with NP, he stated all residents using bed rails (enablers) were required to have an assessment for use of a bed rail (enabler). NP stated if the patient was not strong enough to use them then they were not able to use the bed rails. NP stated not conducting a bed rail assessment would be a risk and would depend on the patient situation. On 01/21/25 at 2:50 PM, the DON, she stated there was no Bed/Transfer/Bar Assessment policy. During an interview on 01/21/25 at 2:55 PM, with the DON, she stated the purpose of a Bed/Transfer/Bar Assessment was to ensure if bed rails (enablers) were safe for the resident or not. The DON stated the risk could be harm and the patient getting their limbs stuck on the bed. The DON stated the nursing staff were responsible for ensuring a Bed/Transfer/Bar Assessment was completed. During an interview on 01/22/25 at 11:05 AM, with the Administrator, she stated the purpose of a Bed/Transfer/Bar Evaluation was to see if the resident needed the bed rails (enablers) or not. The Administrator stated the negative outcome would be that the nursing staff would not be able to use it to see if the resident needed it or not.

Based on observation, interview and record review the facility failed to respect a resident's right to personal privacy during personal care for 2 of 7 residents (Resident #4 and Resident #8) reviewed for respect and dignity. Staff Coordinator did not close the room binds when providing patient care for Resident #4 during weighing Resident #4. CNA A left Resident #8's room leaving the door open exposing Patient #8's brief and private area. These failures could place residents at risk of diminished quality of life, lack of privacy, and lack of dignity. Finding included: Resident #4 Record review of Resident #4's face sheet dated 01/22/25, revealed, admission on 12/17/24 to the facility. Record review of Resident #4's hospital history and physical dated 12/11/24, revealed, an [AGE] year-old female diagnosed with Diabetes Type 2 and right leg pain due to a fall. Record review of Resident #4's admission MDS dated [DATE], revealed, moderate impaired cognition BIMS score of 11 to be able to recall or make daily decisions. ADLs revealed dependent (staff does all the work) for roll left or right, sit to lying, lying to sitting, toileting, showers, dressing lower body. diagnosed with Ankylosing spondylitis of thoracic region (a type of arthritis that causes inflammation in the thoracic spine, or middle of the back). Record review of Resident #4's care plan dated 12/26/24, revealed, decline in mood state. Patients' mood will remain stable or improve. Observation and interview on 01/17/25 at 2:53 PM, with LVN C, she stated she saw state agency observing Staffing Coordinator conducting resident care with the blinds open it and immediately walked into Resident #4's room and closed the binds. LVN C stated the Staff Coordinator should have closed the binds and not left them open because everyone could see what was being done to Resident #4 during patient care. LVN C stated there was no privacy for Patient #4. During an interview on 01/17/25 at 3:20 PM, with Staffing Coordinator, stated he did not close the binds to Resident #4's room when he was providing patient care. Staffing Coordinator stated he did need to close the blinds or window curtains for the Residents dignity. Resident #8 Record review of Resident #8's face sheet dated 01/22/25, revealed, admission on 12/07/24, and re-admission on 01/09/25 to the facility. Record review of Resident #8's hospital history and physical dated 12/28/24, revealed, a [AGE] year-old female diagnosed with Dementia, Fibromyalgia (a chronic condition that causes pain and tenderness in the muscles and soft tissues throughout the body), cervical intervertebral disc herniation (occurs when the soft center of a spinal disc pushes out through a tear in the disc's outer ring). Record review of Resident #8's MDS dated [DATE], revealed, there was no BIMS score completed to assess cognition nor the Residents functional ability. Diagnoses revealed muscle weakness (e muscles lack strength and may not move as easily), muscle wasting (the loss of muscle mass and strength), and lack of coordination. Resident #8 was coded for always incontinent for urinary and frequently incontinent for bowel. Record review of Resident #8's Comprehensive Care Plan dated 12/07/24, revealed, potential/actual decline in ADLs. Provide assistance as needed with grooming, bathing, and personal hygiene and per patients' preferences. Incontinence with bowel/bladder. Check frequently and assist with toileting as needed. Provide peri care after each episode and apply barrier cream as needed. Patient #8 has impaired mobility secondary to weakness and debility. Record review of Resident #8's baseline care plan dated 01/09/25, revealed, dependent (Where nursing staff does all the work) for bed mobility and transfers. Baseline care plan does not indicate any specifics on incontinence care or toileting for Resident #8. Observation on 01/17/25 at 2:45 PM, revealed, CNA A coming out of Resident #8's room heading to get incontinent care items while Resident #8's door remained open exposing Resident #8's brief and private area. During an interview on 01/17/25 at 3:58 PM, with CNA A, she stated she was going to change Resident #8. CNA A stated she left the room to go get the incontinent care items (briefs and pads) that she was going to need for Resident #8. CNA A stated anytime incontinent care was to be performed the curtain or door had to be closed or the Patient covered up to provide privacy. CNA A stated there was no risk for the patient other than the privacy issue. CNA A stated she would be embarrassed if the curtain or door was left open exposing her brief and or private area. During an interview on 01/21/25 at 1:38 PM, with NP, he stated when performing the incontinence care the facility staff should be providing privacy for the patient. NP stated it was a moral issue and it would be a HIPPA but with the patient's body. During an interview on 01/21/25 at 2:51 PM, with the DON, she stated nursing staff were trained on incontinence care and privacy was number one and patients should feel safe and comfortable with care. Record review of the facility Patient Rights: Planning and Implementing Care dated 02/08/21, revealed, The Centers honor our patients' rights to: Equal access to quality of care. The policy given does not indicate anything regarding resident rights for privacy or dignity.

Based on interview and record review the facility failed to ensure that the assessment accurately reflected the patient's status for 1 (Resident #2) of 4 residents reviewed for accuracy of MDS assessment. Resident #2's admission MDS did not accurately reflect the patients' use of bed rails (enablers). This deficient practice could place residents at risk of not receiving adequate care. Findings included: Record review of Resident #2's hospital history and physical dated 11/22/24, revealed, an [AGE] year-old female diagnosed with anxiety and osteoporosis. Record review of Resident #2's face sheet dated 01/21/25, revealed, admission on 12/04/24 to the facility. Record review of Resident #2's order dated 12/04/24, revealed, Enablers - upper to allow use of bed controls and assist with bed mobility. Record review of Resident #2's Assistive Transfer Device Consent dated 12/04/24, revealed, Assistive Transfer Device: The facility utilizes fully functional beds that come equipped with transfer bars. The benefits of theses bars are - 1. Independent control of bed positions. 2. Assist with transferring and reposition. The risks are - 1. Falling. 2. Entrapment. It was signed by Patient/Guardian, nurse, and Patient #2. Record review of Resident #2's baseline care plan dated 12/04/24, revealed, there was no focus area for bed rail (enables) use. Record review of Resident #2's MDS dated [DATE], revealed, little to no cognitive impairment BIMS score of 13 to be able to recall or make daily decisions. ADLs were dependent (staff does all the work) for toileting, roll lift and right, and sit to lying while in bed. Patient #2 was not coded for bed rail (enabler) in Section P - Restraints and Alarms of the MDS. Record review of Resident #2's comprehensive care plan dated 01/21/25, revealed there was no focus area for bed rails (enablers). During an interview 01/17/25 at 2:04 PM, with the DON, she stated she had observed Resident #2's MDS and did not see it was coded for bed rails. The DON stated she was new to nursing home and needed to review with the MDS department regarding the risks but would think there would be a risk. During an interview on 01/21/25 at 11:47 AM, with the MDS Coordinator, she stated the MDS department and nurses were responsible for generating the MDSs and making sure they were correct and accurate. The MDS Coordinator stated Patient #2 was not coded for bed rails (enabler) on the MDS but does use them to assist staff and herself. The MDS Coordinator stated she did not know what the risk would be not having it coded on the MDS. Record review of the facility MDS policy dated 03/14/24, revealed, Policy - It was the policy of this facility that MDS assessments, discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and appropriate assessment will be transmitted to CMS. All staff members will be responsible for completion of the MDS and transmission processes in accordance with the MDS RAI instruction manual.

Based on the observation, interview, and record review the facility failed to ensure that the patients environment remains free of accidents hazards as is possible and each patient received adequate supervision to prevent accidents for 1 (Resident #4) of 4 residents reviewed for accidents. Staff Coordinator was weighing Resident #4 in her room by using a mechanical lift to lift Resident #4 by himself. Staff Coordinator did not lock the mechanical lift brakes when lifting Patient #4 up in the air as he was weighing and then moved the mechanical lift upwards to re-position Patient #4. This failure could affect residents who required the use of a mechanical lift for transfers, by placing them at risk of improper transfers resulting in injury. Findings include: Record review of Resident #4's face sheet dated 01/22/25, revealed, admission on 12/17/24 to the facility. Record review of Resident #4's hospital history and physical dated 12/11/24, revealed, an [AGE] year-old female diagnosed with Diabetes Type 2 and right leg pain due to a fall. Record review of Resident #4's admission MDS dated [DATE], revealed, moderate impaired cognition BIMS score of 11 to be able to recall or make daily decisions. ADLs revealed dependent (staff does all the work) for roll left or right, sit to lying, lying to sitting, toileting, showers, dressing lower body. diagnosed with Ankylosing spondylitis of thoracic region (a type of arthritis that causes inflammation in the thoracic spine, or middle of the back). Record review of Resident #4's baseline care plan dated 12/17/24, revealed, bed mobility - physical assist of two persons and transfer was total dependent. History of falls. Record review of Resident #4's care plan dated 12/26/24, revealed, ADLs related to self-care and deficits and decreased functional mobility was added on 01/20/25 during state agency's visit. Hoyer lift with two aides was also added on 01/20/25 during state agency's visit as there was no ADLs noted before visit date. Record review of facility Weights Form dated 01/15/25, revealed, name of Resident #4 and type of transfer which was hoyer. Observation and interview on 01/17/25 at 2:53 PM, LVN C stated she saw state agency seeing it and immediately walked into Resident #4's room and then came out of the room. LVN C stated the Staffing Coordinator was in the room with Resident #4 and was using the mechanical lift. LVN C stated when using the mechanical lift it required two staff to operate it. LVN C stated this was for the safety of the resident. LVN C stated the mechanical lift brakes where to be applied before lifting Resident #4 into the air. LVN C stated this was for safety reason. LVN C stated the mechanical lift could slide back and forth causing an injury to both staff and patient. During an interview on 01/17/25 at 3:20 PM, with Staffing Coordinator, he stated he was trained on transfers and using the hoyer lifts. Staffing Coordinator stated he was going to take Patient #4's weights but was not going to transfer her. Staffing Coordinator stated he was alone when he performed the weighing. Staffing Coordinator stated using the mechanical lift required two staff when operating it. Staffing Coordinator stated his Weights Form notified him of what transfer Patient #4 was and other patients. Staffing Coordinator stated he did not apply the hoyer lift brakes and he should have. Staffing Coordinator stated the risk for using the hoyer lift with one person and not applying the brakes was a fall and or injury to both the patient or the staff. During an interview on 01/21/25 at 2:51 PM, with the DON, she stated facility staff have been trained on hoyer transfers. The DON stated when using the mechanical lift it did require to have two staff to operate it. The DON stated this was in cases something went wrong. The DON stated the brakes had to be locked before lifting the patient up. The DON stated the risk would be an injury to both the patient and staff. Record review of the facility Mechanical Lifts Policy dated 02/01/23, revealed, Policy - The Centers utilize mechanical lifts when appropriate to ensure safe patient handling during transfers and employee safety when providing patient care. Direct care staff will receive training upon hire and as needed for proper preparation of the patient, equipment, and environment during utilization of mechanical lifts. 2 staff members are required for utilization of the lift. On 01/17/25 at 3:48 PM, a text message was sent to the Administrator requesting an Accidents Policy and nothing was provided to state agency. At the end of exit state agency asked if the facility had anything to provide and nothing else was provided.

Based on observation, interview, and record review it was determined the facility failed to ensure patients who were incontinent received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 2 residents reviewed for incontinent care/Foley catheter care. The facility failed to empty Resident #3's catheter before it got full backing up into the tubing. These failures placed residents at risk for infection and hospitalization . Findings included: Record review of Resident #3's face sheet dated 01/22/25, revealed, admission on 01/16/25 to the facility. Record review of Resident #3's facility history and physical dated 01/17/25, revealed a [AGE] year-old female diagnosed with Diabetes, right ankle displaced Tri-malleolar fracture (a rare, but severe break in the ankle that affects three parts of the ankle bone). Record review of Resident #3's admission MDS dated [DATE], revealed, an intact cogitation BIMS score of 15 to be able to recall and make daily decisions. Patient #3 was always incontinent. MDS did not have the functional abilities coded. Was coded for indwelling catheter. Record review of Resident #3's Order dated 01/16/25, revealed, foley catheter care q shift and as needed. Every shift for foley catheter maintenance. Record review of Resident #3's care plan dated 01/16/25, revealed, incontinent with bowel/bladder. Keep call light within reach and remind Patient #3 to call for assistance. Resident #3 had catheter. Change foley catheter as ordered by physician and as needed. Observation and interview on 01/17/25 at 3:01 PM, with Resident #3, it was observed Resident #3 to be lying in bed. Catheter bag was hanging off the left side of the bed. The catheter bag was full of a dark brownish colored urine. The tubing was filled with pink colored and cloudy substance that went all the way back towards the patient. Resident #3 stated the nursing staff were draining the catheter bag 3-4 times a day. During an interview on 01/17/25 at 3:58 PM, with CNA A, she stated the CNAs were responsible for checking on the catheter bags at the end of every shift when the bag was drained and then documented. CNA A stated if the catheter bag was too full then they will drain it during the day. CNA A stated if the catheter bag was really full then it could cause reverse back flow, going back into the patient causing an infection. CNA A stated if there was anything in the tube such as blood or its too dirty, they are to be reporting it to the nurse to prevent infection. During an interview on 01/21/25 at 1:38 PM, with NP, he stated cloudy tubing and filled catheter bags should be emptied and should not be full. NP stated this was to avoid a UTI. NP stated if there was sediment in the tubing then it should be reported to the nurse. NP stated full or cloudy tubing and catheter bags should be prevented to prevent back flow into the Patient and bacterial growth. During an interview on 01/21/25 at 2:51 PM, with the DON, she stated the CNAs were responsible for reporting an issue with catheter such as the tubing being full, having sediment, and color. The DON stated it was not okay to have sediment in the tubing and need to notify the nurse. The DON stated the CNAs should be changing out the catheter bags when it gets half ways and should be done with their intentional rounds. The DON stated the risk could be back flow and infection. Record review of the facility Foley Catheter Policy dated 02/08/21, revealed, Purpose - The Centers are dedicated to providing the best care possible to patients who entrust us with their care. Policy - If a patient requires an indwelling catheter, the facility will follow routine foley catheter care orders. Notify DON/ADON of issues.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for dietary services. A. Food containers had accumulations of dried drippings and residue on them. B. Food preparation areas had items with accumulation of dust, encrusted grease deposits, and other soiled accumulations. C. Food in refrigerator with expired dates. D. Bananas were stored next to a dirty trash bin. E. The Dietary Manager entered the kitchen without a beard guard. This failure places residents who eat food prepared by the facility at risk of food borne illnesses. The findings include: During an observation on [DATE] at 8:21 AM, revealed one red 1 Gallon plastic bottle that contained dressing that had liquid build up and it was sticky to the touch; a bottle of 1 Gallon Soy Sauce had liquid residual and dried dripping on sides of bottle. A container with soup had residue on the lid. A clear plastic container had 3 1-gallon Ziplock bags containing expired vegetables. Bag #1 was labeled as salad mix with a date of [DATE] with an expiration date of [DATE]. Bag # 2 was labeled with the date of [DATE] with an expiration date of [DATE]. Bag #3 was labeled with a date of [DATE] with an expiration date of [DATE]. During an interview on [DATE] at 8:25 AM, Dietary Aide said residues on bottles could lead to risk of contamination of the plastic containers and bacteria could build up on them. The Dietary Aide also said that storing expired vegetables could lead to illness for the residents in the facility if they were used or if they contaminated other foods in the refrigerator. During an observation on [DATE] at 8:30 AM, revealed plastic containers with Paprika, Parsley Flakes, Ground [NAME] Pepper, Lemon and Pepper Seasoning Salt and Black Pepper had powder residues on the side of the bottle and on the lid. A cooking oil plastic bottle was sitting on top of a paper towel soaked in oil. During observation and interview on [DATE] at 8:35 AM, A box of bananas was next to a dirty trash bin. Interview with the Dietary Aide revealed the bananas should not be next to the trash can and kitchen staff store them on the opposite side of the counter, but she did not know why they were there or who left them there. During an observation on [DATE] at 8:37 AM, Water stains were observed on the walls and on the pantries. The wall towards the back of the deep fryer had white calcium build-up and water stains. During observation and interview on [DATE] at 8:40 AM, the Dietary Manager entered the kitchen without a beard guard, and after a short time said, Excuse me and stepped out of the kitchen, returning wearing a beard guard, although it was not covering his mustache. The Dietary Manager stated that he started working at the facility around February of 2024. Observation of a small refrigerator revealed there were expired flour tortillas with a Preparation date of [DATE] and a Use by date of [DATE]. Interview with Dietary Manager revealed using the flour tortillas on a meal with the use-by date of [DATE] could pose a risk of bacteria growing on the tortillas and that it could result in digestive infections to the residents. During observation and interview on [DATE] at 8:45 AM, Dietary Manager revealed there was a plastic trashcan with a white trash bag inside that was placed in between the grill and the gridle. The trash can had visible signs of food on the lid, and it looked dirty. The grill was dirty and grimy as well as the gridle with signs of grease and dry residues. The Dietary Manager stated that the gridle and the grill were cleaned every week. The Dietary Manager stated that there was no tracking system in place to record when these items were being cleaned. The Dietary Manager stated he did not see issues with the trashcan being near or in between the gridle and the grill. During observation and interview on [DATE] at 8:48 AM, Dietary Manager revealed the deep fryer was dirty with food residues and grease. The back of the fryer had food residues and the oil was dark in color. The Dietary Manager stated the used oil is disposed of weekly and that the fryer is cleaned every week. The Dietary Manager stated that there was no tracking system to record when the fryer has been cleaned. During observation and interview on [DATE] at 9:04 AM, Dietary Manager on the dish washing area revealed the drain at the back of the room where the kitchen floor mats are washed was dirty and clogged with trash and debris. Record review of facility's policy and procedure on Food Storage Policy Dated [DATE] and revised on [DATE] documented in part: Purpose: Food items within the building are to be stored properly to ensure they are optimal for safe consumption by patients and staff. Storing food properly helps to prevent foodborne illness and maintain their food ' s peak qualities such as flavor, texture, color, and aroma. These factors contribute to a positive and enjoyable dining experience. Policy: the same day that food products are delivered to the facility, they are to be inspected for safety and quality. Each item is to be accurately dated upon receipt. When items are opened or in use, Use-by-date are to be labeled upon them followed by storing the item in the proper area such as the refrigerator, freezer, or dry storage area located in the kitchen. All outdated, expired, or damaged food products are to be discarded immediately. Proper food sanitation guidelines are to be followed. Involved Personnel: Food items belonging to the facility may be handled by the dietary department. Procedure: Facility food storage: refrigerated, frozen, and dry storage items. Refrigerated items: storing foods in the refrigerator slows bacterial growth and can help prevent foodborne illness. All items requiring refrigeration should be stored at temperatures of 36 - 41 F or below and are to be dated properly. The FIFO method (first in first out method) is to be used with all items to ensure proper rotation. Fresh fruits and vegetables should be placed in bins, cartons, or bags to promote freshness. Expired or damaged foods are to be discarded and not consumed. Review of facility's policy and procedure on Use of Gloves/Hairnets/Covering of food, dated [DATE] and revised on [DATE] revealed in part: Hair nets are to be used when cooking or preparing food. Hair nets are not required when delivering food. Ex: cooking food such as stirring pots or assembling ingredients. Policy & Procedure Manual. General Sanitation of Kitchen. Policy: food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Procedure: Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Tasks will be assigned to be the responsibility of specific positions. Frequency of cleaning for each task will be defined. Methods and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task. Employees will be trained on how to perform cleaning tasks. On the cleaning schedule, employees will initial and date tasks when completed. (Refer to chapter 5: cleaning instructions for sample cleaning schedule and sample cleaning forms.) Employees will wear rubber gloves and an apron to protect hands and clothing while cleaning the kitchen. Protective eyeglasses will be worn as appropriate. The safety data sheets (SDS) will be available for all chemicals used by the food and nutrition services staff. Employees will be in-service on the proper use of chemical and SDS Sheets. Resource: OSHA Quick Card. Hazard Communication Safety Data Sheets, https://www.osha.gov/Publications/HazComm QuickCard SafetyData.html.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for three (Resident #35, Resident #89 and #192) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #35 ' s baseline care plan included her expressed preference for a vegetarian diet. The facility failed to ensure that Resident #89 ' s Baseline Care Plan addressed her Diabetes II. The facility failed to ensure that Resident #192 ' s baseline care plan included pressure reducing boots and that a copy was given to the resident and the resident ' s representative. These failures put residents at risk of not having their dietary needs and preferences met, not having their treatment needs associated with diabetes met and not receiving physician-ordered treatments. Findings included: Resident #35 Record review of Resident #35 ' s face sheet, dated 04/18/2024, revealed she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #35 ' s hospital history and physical, dated 03/27/2024, revealed she had severe osteoporosis (weak and brittle bones), a closed fracture of the left tibial plateau (broken left knee); fracture of humeral head, left, closed (broken left shoulder); closed fracture fibula, head (broken leg); and systematic lupus erythematosus (illness when the immune system attacks healthy tissue). Orders included that she was to have a vegetarian diet (page 45). Record review of Resident #35 ' s Baseline care plan, dated 03/29/2024, revealed Diet Order for regular diet, she was at risk for weight loss, with a nutritional goal of maintaining current weight. Preferences included that she liked to eat in her room. The Baseline care plan did not state that the resident followed a vegetarian diet. Record review of Resident #35 ' s Diet Order dated 03/29/2024 revealed she was to receive a regular diet. It stated ***PT [patient] IS VEGETARIAN***. Record review of Resident #35 ' s MAR for April 2024 revealed the words Vegetarian diet at the top of each page. Record review of Resident #35 ' s nursing progress notes dated 03/29/2024 through 04/18/2024 revealed no notes indicating she was receiving a vegetarian diet. In an interview on 04/16/24 at 04:28 PM Resident #35 revealed she was a vegetarian and wondered if a dietitian had looked at her diet. She expressed concern that she was not getting a balanced diet and said a family member brought in food to supplement her diet. She said she talked to staff, including dietary staff, about being a vegetarian but continued to be concerned that she was not getting good nutrition. In an interview and record review on 04/19/24 at 1:54 PM the Dietary Manager said he was aware that Resident #35 followed a vegetarian diet. He said he had assessed her dietary preferences, and the resident wrote him notes regularly on diet slips indicating what she wanted and how the food provided worked for her. Record review revealed seven dietary slips the Dietary manager had received from Resident #35 regarding preferences and concerns. In a telephone interview on 04/19/24 at 02:04 PM the Dietitian recalled working with a resident who was vegetarian. The Dietitian thought the dietary software used by the facility might have an algorithm to calculate dietary needs for a vegetarian. The Dietitian said she had talked with the Dietary Manager about Resident #35 ' s dietary needs and advised him that if there were animal proteins such as milk products in each meal the resident ' s diet should be adequate. In an interview on 04/19/24 at 03:33 PM the MDS Coordinator RN stated that Resident #35 ' s preference for a vegetarian diet should be care planned under preferences. The reason this should be done was so the facility could follow vegetarian guidelines. The risk to resident of not having her vegetarian dietary preferences on the baseline was that the facility might not follow through on her vegetarian diet preferences. The MDS Coordinator RN stated that she did not know if there were risks to a person following a vegetarian diet but that they might lack certain vitamins that are found in meat but not in vegetables, and result in vitamin deficiency. Resident #89 Closed record review of Resident #89 ' s face sheet dated 04/18/2024 revealed she was [AGE] years old and was admitted to the facility on [DATE]. It indicated she had diagnoses including Type 2 Diabetes Mellitus with Other Diabetic Kidney Complication. Closed record review of Resident #89 ' s electronic census record revealed she was discharged on [DATE]. Closed record review of Resident #89 ' s hospital history and physical dated 10/21/2023 revealed she had a medical history including Type 2 diabetes with renal (kidney) complications. The plan for diabetes was to have her on low dose sliding scale insulin (amount of insulin given depends on her blood sugar test). Discharge instructions included monitoring her blood sugar and stated that her health care provider would set individualized treatment goals for her to maintain blood glucose levels within specified ranges. Closed record review of Resident #89 ' s Admission MDS dated [DATE] revealed her diagnoses included diabetes mellitus. She was not receiving hypoglycemic (medicine to treat diabetes) medications. The CAA triggered the care area of nutritional status and indicated that a decision about care planning needed to be made about her nutritional status. Closed record review of Resident #89 ' s physicians orders from 11/13/2023 through 12/09/2023 revealed no orders for medications or for monitoring of diabetes mellitus. Record review of Resident #89 ' s baseline care plan dated 11/13/2023 revealed no care plans related to diabetic management. In an interview on 04/18/24 at 01:33 PM Resident #89 ' s family member revealed that the resident had been taking insulin when she was still living at home, but the family member did not remember if the resident was being given insulin in the facility. In an interview on 04/18/24 at 02:15 PM RN A revealed that she had worked with Resident #89 on several occasions and that there were no orders to check her blood sugar. The RN stated she was not aware Resident #89 had diabetes. In an interview on 04/19/24 at 03:32 PM the MDS Coordinator RN revealed she was unaware that Resident #89 had a diagnosis of diabetes. She said that if a resident had a diagnosis of diabetes, it should be on the baseline care plan because it was important to monitor for symptoms even if the resident was not receiving medications for the diagnosis. Resident #192 Record review of Resident #192 ' s face sheet dated 04/18/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #192 ' s wound management dated 04/12/2024, revealed physician orders for pressure reducing boots. Record review of Resident #192 ' s Baseline care plan dated 04/11/2024 revealed the following: Patient and Representative did not sign or attend the baseline care plan. Resident did not have pressure reducing boots included in the baseline careplan. In an interview on 04/16/24 at 10:20 AM Resident #192 revealed that he has been wearing pressure reducing boots from the hospital. He stated that he is supposed to wear them whenever he is in bed. Resident #192 stated that he was not given a copy of the baseline care plan nor was he asked any questions concerning his care. In an interview and record review on 04/17/24 at 3:00 PM, the DON said she was aware that Resident #192 was to wear pressure reducing boots to upload the pressure from his heels while he was in bed. She stated that she was made aware that residents and their representatives were not being included in the baseline care plan process or receiving a copy of it after completion. She revealed that the pressure reducing boots should have been completed in the baseline care plan. She stated that they did a regional audit and were trying to correct the issue. She stated that this failure could place residents at risk of not being included in the admission process. She said she was going to start a new process where it would be part of the admission packet and had to be signed with the other paperwork. She revealed that it was the LVN ' s that was admitting the resident to complete the baseline care plan, but she was responsible for checking for accuracy and completion. Record review of the facility policy Baseline Care Plan revised 06/30/2022 revealed that the facility must develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that reflects the resident ' s goals and objectives and includes interventions that address the resident ' s current needs. 45437