Every finding on record at Cheyenne Medical Lodge

Based on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Residents #1) of sixteen residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #1's Quarterly MDS assessment dated [DATE] accurately reflected that the resident exhibited rejection of care behaviors related to his ADLs as documented on his Comprehensive Care Plan, progress notes, and shower sheets. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Review of Resident #1's Face Sheet dated 07/10/26 revealed he was a [AGE] year-old male admitted to the facility on [DATE] for rehabilitation. Relevant diagnoses included COPD (progressive lung disease making it difficult to breathe,) chronic kidney disease (progressive decrease in kidney function,) type 2 diabetes (insulin resistance,) and right leg amputation (surgical removal.) Review of Resident #1's Quarterly MDS dated [DATE] revealed he had moderate cognitive decline with a BIMS score of 10. It was documented that he did not exhibit any rejection of care behaviors. Resident #1 had functional limitations, with impairments on one of his lower extremities; he required a wheelchair for mobility. Resident #1 required staff supervision for toileting, personal hygiene, and upper body dressing. He required partial, moderate assistance from staff with shower/baths. He did not have any external devices and/or appliances (i.e. indwelling catheter, ostomy, etc.) Resident #1 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #1's Comprehensive Care Plan dated 05/12/26 revealed: 04/21/26 Resident #1 was resistive to care and refuses to be changed or receive peri care at times. Interventions included: Allow the resident to make decisions about treatment regime to provide a sense of control Educate family/caregivers of the possible outcomes of not complying with treatment of care Give clear explanation of all care activities prior to care Praise the resident when behavior is appropriate Provide resident with opportunities for choice during care Review of Resident #1's Skin Observation for Showers provided for review 07/11/26 at 2:30 pm revealed resident was repeatedly resistive to ADLs. 06/04/26 Resident #1 refused a bath. 06/09/26 Resident #1 refused a bath. 06/11/26 Resident #1 refused a bath. 06/27/26 Resident #1 refused a bath. 06/30/26 Resident #1 refused a bath with perineal and flank areas documented as rash. In interview with facility MDS nurse on 07/12/26 at 11:08 am she stated she compiled information from a resident's EMR to complete her assessments; and Resident #1's refusals were not available to her electronically. She stated she would start reviewing any paper documents moving forward to ensure compliance. She stated it was her responsibility to ensure MDS assessments were completed timely and accurately as it presented a full picture of the resident's care and what they need at the facility. In interview with facility DON on 07/12/26 at 11:30 am she stated Resident #1 was known to be resistive to cares and her expectations were for that to be documented on his MDS. DON stated this was to be completed by the MDS nurse and it was her direct responsibility to ensure MDS assessments were completed accurately. She stated this was important because a resident's MDS needed to be accurate for safety and quality purposes. Review of facility policy Resident Assessment provided by the facility's DON on 07/11/26, undated, revealed It is the policy of this facility to conduct and document. a comprehensive, accurate, standardized, and reproducible assessments on a residents functional capacity.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eighteen residents (Resident #44, #126, and #137) reviewed for infection control. 1.The facility failed to ensure CNA F performed hand hygiene, changed her gloves, and wore a gown during Resident #126's incontinent care on 06/14/2026. 2.The facility failed to ensure CNA F and CNA G wore gowns when Resident #126, who was on enhanced barrier precautions due to pressure ulcer, was repositioned on 06/14/2026. 3.The facility failed to ensure MA D sanitized the blood pressure cuff when used between Resident #44 and Resident #137 on 06/14/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1.Record review of Resident #126's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #126's Comprehensive MDS Assessment, dated 05/08/2026, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident was incontinent and was at risk of pressure ulcer (wound on the skin caused by prolonged pressure to specific areas of the body). Record review of Resident #126's Comprehensive Care Plan, dated 06/04/2026, reflected the resident required assistance with ADLs and had a stage four pressure ulcer to left lateral malleolus. The interventions were to provide support with toilet use and to provide wound care. Record review of Resident #126's Physician Order, dated 06/12/2026, reflected LEFT LATERAL (from the sides) MALLEOULUS (bone in the ankle): STAGE 4 Clean wound bed with wound cleanser or normal saline, pat dry, cover with Foam dressing one time a day. The order indicated that the resident had the pressure ulcer since 05/29/2026 and was edited on 06/12/2026. During an observation on 06/14/2026 at 9:24 a.m., CNA F was about to do Resident #126's incontinent care, who had a pressure ulcer to left ankle. He went inside the room and put on a pair of gloves. He did not wash his hands before putting on his gloves. He also did not wear a gown before doing incontinent care. He took a brief from a plastic bag, opened it, and placed it on the resident's side. He unfastened the soiled brief, tucked it between the resident's legs, and rolled the resident to his side. He then cleaned the resident's bottom. After cleaning the resident's bottom, he applied some cream to the resident's bottom using the same gloves used in cleaning the resident's bottom. After applying the cream, he changed his gloves but did not sanitize his hands before putting on a new pair of gloves. He then pulled the soiled brief and threw it on the trash can. He took the opened brief from the resident's side, placed it under the resident, and fixed it under. He did not change his gloves after touching the soiled brief. After fixing the brief, he rolled back the resident, cleaned the resident's perineal area (area between the legs) with the same gloves that touched the soiled brief, and fastened the brief. It was observed that during the process of incontinent care, CNA F was leaning on the resident's bed. After he was done with incontinent care, he took off his gloves and told the resident that he would call somebody to help him reposition the resident. He went out of the room but did not wash his hands before leaving the room. There was a sign outside the resident's room that stated the resident was on EBP, and a gown was required when changing the brief. The sign also indicated to clean the hands before entering and when leaving the room. 2.During an observation on 06/14/2026 at 9:34 a.m. revealed CNA F and CNA G were about to reposition Resident #126. CNA F put on a pair of gloves but did not wash his hands before putting on a pair of gloves. CNA G went to the bathroom, washed her hands, put on a pair of gloves, and proceeded to reposition the resident. Both CNAs did not have a gown, and both CNAs were leaning on the resident's bed. There was a sign observed outside the resident's room that the resident was on EBP, and a gown was required during transfer. The sign also indicated to clean the hands before entering and when leaving the room. During an interview on 06/14/2026 at 9:37 a.m., CNA F said he should wash his hands before incontinent care and repositioning the resident, before putting on a pair of gloves, should have sanitized his hands when he changed his gloves, and changed his gloves after pulling the soiled brief. He said the purposes of the procedures mentioned were to prevent cross contamination and spread of infection. He said he was not aware Resident #126 was on EBP. He said he saw the sign but did not bother to check for whom the sign was for. He said since the resident was on EBP, then PPE was required for the same reason. He said he was trained in infection control but did not know why he forgot to practice them when he did incontinent care and repositioning. During an interview on 06/14/2026 at 9:40 a.m., CNA G said she was not aware Resident #126 was on EBP. She said she thought the EBP sign was for Resident #126's roommate. She looked at the EBP sign and realized the sign was for Resident #126. She said if a resident required EBP, a gown should be worn even when repositioning the resident because it was a high contact activity. She said a gown should have been worn to prevent cross contamination. 3.Record review of Resident #44's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #44's Comprehensive MDS Assessment, dated 04/08/2026, reflected the resident had a severe impairment with cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #98's Comprehensive Care Plan, dated 05/28/2026, reflected the resident had hypertension and one of the interventions was to administer medication as ordered. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Losartan Potassium 50 MG Tablet Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD If SBP less than 100 or DBP less than 60 **IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Metoprolol Succinate ER Oral Tablet Extended-Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD If SBP less than 100 or DBP less than 60 OR PULSE less than 60. IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #137's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #137's Comprehensive MDS Assessment, dated 05/22/2026, reflected the resident had a moderate (resident may need additional support and monitoring) impairment with cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated that the resident had hypertension. Record review of Resident #137's Comprehensive Care Plan, dated 05/28/2026, reflected the resident had hypertension and one of the interventions was to administer medication as ordered. Record review of Resident #137's Physician Order, dated 07/27/2025, reflected Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN HOLD FOR SBP <100 OR DBP < 60 OR PULSE < 60. During an observation on 06/14/2026 starting at 11:29 a.m. revealed MA D went inside Resident #137's room with a bp cuff. She then came out of Resident #137's room holding a bp cuff and placed it on top of the medication cart, prepared Resident #137's medication, and gave the medications to Resident #137. She did not sanitize the blood pressure cuff after use. She then went to Resident #44's room to check the resident's blood pressure. She picked up the blood pressure cuff from the medication cart and went inside the resident's room and placed the blood pressure cuff on the resident's arm. After the blood pressure reading was completed, MA D placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #44. She did not sanitize the blood pressure cuff after use. During an interview on 06/14/2026 at 11:57 a.m., MA D said the facility protocol was to sanitize the bp cuff in between use to prevent cross contamination. She said one resident might have a skin issue and might be transferred to another resident because the bp cuff was not sanitized. During an interview on 06/16/2026 at 9:03 a.m., ADON A said the staff should be mindful they were not causing any spread of infection in the facility and one way to do that was to do hand hygiene before, after, and during any care. She said the staff should change their gloves after cleaning the resident's bottom to make sure the staff were not using soiled gloves when they touched the new brief and should sanitize the hands before putting on a new pair of gloves. She said another way to prevent the spread of infection was to wear PPE when residents were on EBP. She said residents with pressure ulcers were on EBP to prevent any microorganism from the residents from clinging to the clothes of the staff. She said the purpose of EBP was to prevent the spread of MDRO (Multi-Drug-Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics). She said, during incontinent care, the procedure would always be from clean to dirty, meaning gloves should have been changed before touching the new brief. She said the bp cuff should have been sanitized in between use for the same reason. She said the blood pressure cuff should be sanitized in-between use also to prevent cross contamination. She said she would coordinate with the DON about the issues discussed. During an interview on 06/16/2026 at 9:15 a.m., the DON said hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene before and after any care, said gloves should be changed after cleaning the resident's bottom and before touching the new brief, said hands should be sanitized before putting on a new pair of gloves, and a gown should have been worn if the resident was on EBP. She said the blood pressure cuff should be sanitized after using it. She said not following the policies and procedures of infection control could contribute to cross contamination, development of infection, and spread of infection. She said the expectation was for the staff to adhere to the policies and procedures of infection control. She said she would start an in-service about infection control. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said the expectation was for the staff to wash their hands before and after any care, change their gloves and sanitize their hands when needed, sanitize their hands and bp cuff when required, and put on a gown when the residents were on EBP. She said the blood pressure cuff should be cleaned before using it on another resident. She said the concerns discussed could attribute to the development and spread of infection. She said she would coordinate with the DON regarding the issues discussed. She said she would personally monitor that the staff understood the in-service and not make the same mistake again. Record review of the facility's policy Hand Washing undated, reflected Policy: Hand washing is required before and after a procedure that involves direct or indirect contact with a resident, after contact with any wastes or contaminated materials. Record review of the facility's policy Infection Prevention and Control Program undated, reflected Policies and procedures . Appropriate cleaning, storage, disinfecting, disposal of equipment . Low level disinfection is used for non-critical equipment. Record review of the facility's policy Enhanced Barrier Precaution Infection Prevention and Control Program, undated, reflected Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug-Resistant Organisms: refers to microorganisms that are resistant to one or more antibiotics) to staff hands and clothing. EBP are indicated for residents with any of the following . Wounds . Wounds generally include . pressure ulcers.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four of eighteen residents (Residents #14, #23, #95, and #131) reviewed for medication storage. 1.The facility failed to ensure that Resident #14's zinc oxide was not on top of the resident's side table on 06/14/2026. 2.The facility failed to ensure that Resident #23's zinc oxide was not on top of the resident's side table on 06/14/2026. 3.The facility failed to ensure that Resident #131's zinc oxide was not on top of the resident's side table on 06/14/2026. 4.The facility failed to ensure that Resident #95 did not have a tube of Estradiol Vaginal Cream and a container of pain relief cream inside her room on 06/14/2026. These failures could place the residents at risk of misuse of medications and possible adverse reactions.Findings included: 1.Record review of Resident #14's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/13/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #14's Comprehensive Care Plan, dated 05/27/2026, reflected the resident was incontinent for bladder and bowel and one of the interventions was to apply moisture barrier every shift as preventive measure. Record review of Resident #14's Clinical Assessment List, dated 06/14/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 06/14/2026 at 9:02 a.m., Resident #14 was in his bed, awake. It was observed that a sachet of zinc oxide (medicated cream used to prevent skin irritation) cream was on top of the resident's side table. The cream was on plain view and was easily accessible. The resident said the staff use the cream everytime they change his brief. 2.Record review of Resident #23's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia. Record review of Resident #23's Comprehensive MDS Assessment, dated 04/27/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #23's Comprehensive Care Plan, dated 01/06/2025, reflected that the resident was incontinent and one of the interventions was to provide incontinent care. Record review of Resident #23's Clinical Assessment List, dated 06/14/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 06/16/2026 at 9:14 a.m., Resident #23 was in her bed, awake. A tube of zinc oxide cream was observed on the resident's side table. The cream was in plain view and could be easily accessible. The resident said the staff would use it every time they changed her. She said she was not sure who left the skin barrier on her side table. 3.Record review of Resident #131's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia and reflux uropathy (urine flows backward from the bladder into the kidneys). Record review of Resident #131's Quarterly MDS Assessment, dated 06/02/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment indicated that the resident was incontinent. Record review of Resident #131's Comprehensive Care Plan, dated 04/15/2026, reflected the resident required assistance with ADLs and one of the interventions was to provide level of support for toilet use. Record review of Resident #131's Clinical Assessment List, dated 06/14/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 06/14/2026 at 9:17 a.m., Resident #131 was in her bed, awake. A tube of zinc oxide cream was on top of her side table. She said she did not know what the cream was for, but she would always see it on her side table. The cream was in plain view and could be easily accessible. During an observation and interview on 06/14/2026 at 11:18 a.m., CNA E said zinc oxides should not be inside the residents' rooms because confused residents might accidentally consume them, thinking that the cream was something edible. She went inside the rooms of Residents #14, #23, and #131 and took the zinc oxides from inside the rooms. She said she did not know who left the zinc oxides inside the rooms of the residents. She said there would be residents who would wander around the facility that might go inside other residents' rooms and might take the zinc oxides with them. During an interview on 06/16/2026 at 9:03 a.m., ADON A said zinc oxide was a form of medicated cream because it had ingredients that would prevent skin issues. She said zinc oxides should not be inside the residents' rooms and should be in the carts and should be secured so the residents, especially the confused residents, would not get a hold of them. She said residents with poor eyesight could mistakenly think that zinc oxides were sauce and put them on their food or mistakenly use as toothpaste. She said the cream, when consumed, might cause adverse reactions. She said she would coordinate with the DON about the zinc oxides inside the rooms of the residents. During an interview on 06/16/2026 at 9:15 a.m., the DON said zinc oxide should not be within reach of the residents because residents might use them inappropriately and could result in adverse reactions. She said zinc oxide was applied topically and could be harmful when ingested. She said the expectation was for the staff not to leave the zinc oxides accessible to the residents. She said she would start an in-service about medication storage. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said the expectation was for the staff to make sure there was no zinc oxides on the side tables of the residents because the residents might consume the medications or use them inappropriately. She said the facility had a population of confused residents and those who wandered around that might be able to grab the zinc oxides. She said she would coordinate with the DON about the issue. She said she would personally monitor that the staff understood the in-service and not make the same mistake again. 4.Record review of Resident #95's face sheet dated 06/16/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis included acute kidney failure (kidneys stop working), depression (persistent feeling of sadness or loss of interest) and hypertension, (high blood pressure). Record review of Resident #95's MDS assessment dated [DATE] revealed a BIMS score of 11 indicating she was moderately cognitively impaired. Record review of Resident #95's comprehensive care plan dated 06/08/2026 reflected that she used an anti-depressant and one of the interventions was to monitor for side effects and effectiveness. Record review on 06/16/2026 of Resident #95's Physician Orders reflected an order for the vaginal cream to be administered by a nurse. There was no order for the pain cream. Record review of Resident #95's Clinical Assessment Notes, dated 06/16/2026, reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. In an observation and interview on 06/14/2026 at 9:52 a.m. Resident #95 had a tube of Estradiol Vaginal Cream (Estradiol (estrogen) is a female hormone used to help alleviate symptoms of menopause, including vaginal dryness and burning) on the over bed table, when asked what that was, she stated she had forgotten to use it last night. She stated she had not yet used the pain cream that was on the nightstand. In an interview on 06/15/2026 at 11:51 a.m. with LVN I revealed she was not aware that Resident #95 had any medications at bedside. She stated those should not be in the room and the risk to the resident was it could be used for the wrong reason or the wrong amount used. In an interview on 06/16/2026 at 1:35 p.m., the DON stated that no medication should be at the resident's bedside, and she expected her staff to remove items that are not allowed. She stated the risk to the residents is that the medication could not be administered correctly. Record review of the facility's policy, Storage of Drug Operational/Resident Care Policies, undated, reflected, All drugs and biologicals are stored in locked compartments.

Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for seven of twenty residents (Residents #14, #36, #51, #101, #102, #126, and #150) reviewed for privacy and confidentiality. 1.The facility failed to ensure CNA F closed the door and pulled the privacy curtain while doing Resident #126's incontinent care on [DATE]. 2.The facility failed to ensure LVN C secured Residents #14, #36, #51, #101, #102, and #150's medical information before leaving his cart on [DATE]. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided, which could result in the residents feeling uncomfortable during care and having their personal and medical record exposed to unauthorized individuals.Findings included: 1.Record review of Resident #126's Face Sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body). Record review of Resident #126's Comprehensive MDS Assessment, dated [DATE], reflected that the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #126's Comprehensive Care Plan, dated [DATE], reflected that the resident required assistance with ADLs and one of the interventions was to provide level of support to complete toilet use and personal hygiene. During an observation on [DATE] at 9:24 a.m., CNA F was about to do Resident #126's incontinent care. He went inside the resident's room, put on a pair of gloves, and proceeded with incontinent care. He did not close the door nor pull the privacy curtain. During an interview on [DATE] at 9:33 a.m., CNA F said the door should be closed when performing incontinent care because somebody might walk inside and would see the care being done. He said the privacy curtain should be closed as well because the roommate or the roommate's family member might go inside the room and see the resident without any brief on. She said the door should be closed, and the privacy curtain should be pulled to provide privacy. 2.Record review of Resident #14's Face Sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was on DNR (Do Not Resuscitate: refuse CPR if the heart or breathing stops) and was admitted to hospice. Record review of Resident #36's Face Sheet, dated [DATE], reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (stroke, insufficient oxygen in the brain), polyarthritis (inflammation of five or more joints), and hypertension (high blood pressure). The Face Sheet indicated the resident was on full code (life-saving measures would be provided if the heart stops). Record review of Resident #36's Progress Note, dated [DATE], reflected Appointment Date and Time: [DATE] at 6:30 am . NPO (nothing by mouth) at midnight . hold Eliquis 2 days . hold losartan 24 hr prior. Record review of Resident #36's Physician Order, dated [DATE], reflected BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) = Resident to wear BiPAP at Bedtime. Record review of Resident #36's Physician Order, dated [DATE], reflected Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain. Record review of Resident #51's Face Sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason) and anxiety (intense or excessive fear or worry). The Face Sheet indicated the resident was on DNR. Record review of Resident #51's Physician Order, dated [DATE], reflected Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 4 hours related to UNSPECIFIED DEMENTIA, UNSPECIFIED . AND ANXIETY. Record review of Resident #51's Physician Order, dated [DATE], Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 1 ml by mouth every 4 hours for ANXIETY/AGITATION (restlessness). Record review of Resident #101's Face Sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. The Face Sheet indicated the resident was on full code. Record review of Resident #102's Face Sheet, dated [DATE], reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep) and was on full code. Record review on Resident #102's Physician Order, dated [DATE], reflected CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) = Resident to wear CPAP QHS, set at PS (additional pressure applied during inspiration) 8 QHS. Check placement, setting, and functioning daily. every night shift. Record review on Resident #102's Physician Order, dated [DATE], reflected MID-LINE (a long and thin tube inserted into a large vein in the upper arm used for medication administration) STAT. Record review of Resident #102's vital signs, dated [DATE], reflected blood pressure: 126/65; temperature: 97.2; pulse: 76; respiration: 16; and oxygen saturation: 96%. Record review of Resident #102's Progress Note, dated [DATE], reflected nursing interventions: . new midline placed [DATE] LUA. Record review of Resident #150's Face Sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was on full code. During an observation on [DATE] at 10:55 a.m. revealed LVN C was called to attend to one of the residents. He locked his cart and went inside the resident's room. He left his cart in the middle of the hall with an untitled piece of paper left on top of the cart. On the piece of paper was written Resident #36's name, advance directive and was on hospice; Resident #36's name, appointment date, when he needed to be on NPO, what medications were to be held before the appointment, the resident was using a BiPAP, that the resident was on pain management, and the resident was full code; Resident #51's name, was receiving morphine and lorazepam, and was on DNR; Resident #101's name and was full code; Resident #102's name, had a midline to LUA, used a CPAP, and was on full code; Resident #150's name and was on full code. During an interview on [DATE] at 11:08 a.m., LVN C said he was already inside the resident's room when he realized he did not flip over the shift report on top of his cart. He said he should have turned the paper over before leaving his cart because what was written on the piece of paper was some of the residents' medical information and should be kept confidential. He said the paper should have been secured to prevent HIPAA violations. During an interview on [DATE] at 9:03 a.m., ADON A said staff should always close the door and pull the privacy curtain everytime they provide care to provide privacy. She said residents and family members could step inside the room and might see the resident being changed, or the people in the hallway might see the care being done. She said the staff should always provide privacy during care. She said the piece of paper was the nurses' 24-hour report and had some medical information that was supposed to be confidential. She said the report should have been left in the nurses' station. She said there was a binder in the station for the shift reports. She said if the nurse preferred to bring the report with them, they could put it inside the drawer or under the laptop before leaving the cart. She said she would coordinate with the DON regarding privacy and securing confidential information. During an interview on [DATE] at 9:15 a.m., the DON said what was written on the shift report was confidential information and should not be left exposed. She said the paper should have been turned over, placed inside the cart, or placed under the computer. She said there was a binder in the nurses' station where the nurses could put the report. She said doors should be closed, and privacy curtains should be pulled everytime the staff perform care to provide privacy. She said she would start an inservice about privacy and confidentiality of records. During an interview on [DATE] at 9:41 a.m., the Administrator said the resident's medical information should be protected and could be a HIPAA violation when exposed. She said residents should be given privacy for all the care provided. She said she would coordinate with the DON regarding the issues discussed. She said she would personally monitor that the staff understood the in-service and not make the same mistake again. Record review of the facility's policy, Privacy and Confidentiality Operational/Resident Care Policies, undated, reflected Residents' personal and clinical records are protected to assure confidentiality . Personal privacy will be provided for . personal care . A nursing home resident has the right to personal privacy of not only his/her own physical body, but also . personal care . All information that contains personal identification or descriptions which would uniquely identify an individual resident or a provider of health care is considered to be personal and private and will be kept confidential.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for 2 (Resident # 96 and Resident #95) of 10 residents reviewed for accident and hazards. 1.The facility failed to ensure a bottle of rubbing alcohol was not left on Resident #96's nightstand next to her bed on 06/14/2026. 2.The facility failed to ensure Resident # 95 did not have a can of aerosol hairspray on the overbed table next to her bed on 06/14/2026.3. The facility failed to ensure medications and biologicals were stored in a secure manner by leaving Micro-Kill wipes unattended on a medication cart without staff supervision. These failures could place residents at risk of injuries and exposure to toxic chemicals.Finding included:Record review of Resident #96's face sheet dated 06/16/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis included osteomyelitis of vertebra, thoracic region (a localized infection of the bones in the mid to upper back), unspecified dementia (a clinical diagnosis used when a patient clearly has symptoms of cognitive decline or memory loss) and mood disorder. Record review of Resident #96's PPS (Prospective Payment System) Scheduled Assessment for Medicare Part A Stay MDS assessment dated [DATE] revealed a BIMS of 12, indicating she was moderately cognitively intact.On 6/14/26 at 9:11 AM, the surveyor observed a container of Micro-Kill wipes on an unattended medication cart located in front of room [ROOM NUMBER]. No nursing staff were present with or monitoring the medication cart at the time of the observation.During an observation and interview on 06/14/2026 at 9:17 a.m. revealed a plastic container of rubbing alcohol that was sitting on the nightstand next to Resident #96's bed. She stated she did not know why it was there or how long it had been there. On the back of the container there was a note that said, Keep out of reach of children.During an interview on 06/15/2026 at 9:42 a.m., RN A stated she was not aware the alcohol was in the room and said it should not be there, she stated the risk to the resident was that it could be ingested by someone who didn't know what it was. Record review of the facility's undated policy Operational/Resident Care Polices stated in part . All poisonous items and or other items with cautionary labels are kept secured and are only accessible to employees. Record review of Resident #95's face sheet dated 06/16/2026 reflected a [AGE] year-old female admitted on [DATE]. Her diagnosis included acute kidney failure, depression and hypertension, (high blood pressure). Record review of Resident #95's MDS assessment dated [DATE]revelaed a BIMS of 11 indicating she was moderately cognitively intact.During an observation and interview on 06/14/2026 at 9:50 a.m. revealed a can of aerosol hairspray that she stated her daughter had brought her. She was not aware she was not supposed to have that in her room. In an interview on 06/15/2026 @ 12:06 p.m., LVN B stated she was not aware that Resident # 95 had aerosol hairspray, she stated the risk was that someone who was confused could get a hold of it.

Based on observations, record reviews, interviews, the facility failed to ensure that the medication error rate was not five percent or greater. Eleven medication administration errors were identified out of 25 opportunities, yielding a 44.4% error rate for one of five residents (Resident #44) reviewed for medication errors. The facility failed to ensure MA D did not give Resident #44's eight o'clock and nine o'clock medications at 11:30 a.m. on 06/14/2026. This failure could place the residents at risk for treatment failure, disease progression, reduced effectiveness, and adverse reactions.Findings included: Record review of Resident #44's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia, pleural effusion, drug-induced constipation, GERD, rheumatoid arthritis, hypertension, and anxiety. Record review of Resident #44's Comprehensive MDS Assessment, dated 04/08/2026, reflected the resident had a severe impairment with cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had medically complex conditions. Record review of Resident #44's Comprehensive Care Plan, dated 05/28/2026, reflected the resident was at risk of complications and one of the interventions was administer medications at the same time of the day. Record review of Resident #44's Physician Order, dated 04/25/2026, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by mouth one time a day for GERD. The medication was scheduled to be administered at 9:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Lidocaine External Patch 4 % (Lidocaine) Apply to AFFECTED AREA topically one time a day for Pain and remove per schedule. The patch was scheduled to be applied at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Losartan Potassium 50 MG Tablet Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD If SBP less than 100 or DBP less than 60 **IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Metoprolol Succinate ER Oral Tablet Extended-Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD If SBP less than 100 or DBP less than 60 OR PULSE less than 60. IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350). Give 17 grams by mouth one time a day for STOOL SOFTENER. Give 1 scoop (=17gm) mixed in 6-8oz of fluid. Document amount taken. The Miralax was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 04/25/2026, reflected Paroxetine HCl Oral Tablet 30 MG (Paroxetine HCl) Give 1 tablet by mouth one time a day related to OTHER SPECIFIED DEPRESSIVE EPISODES. The medication was scheduled to be given at 9:00 a.m. Record review of Resident #44's Physician Order, dated 04/29/2026, reflected Hydroxychloroquine Sulfate Tablet 200 MG Give 1 tablet by mouth two times a day related to RHEUMATOID ARTHRITIS, UNSPECIFIED (M06.9) for 90 Days. The medication was scheduled to be given at 9:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Senna S Oral Tablet 8.6 - 50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day for Constipation. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/16/2026, reflected Ipratropium Bromide Nasal Solution 0.06 % (Ipratropium Bromide [Nasal]) 2 sprays in both nostrils three times a day for Rhinorrhea. The medication was scheduled to be given at 8:00 a.m. During an observation and interview on 06/14/2026 at 11:37 a.m., revealed MA D was passing medications in hall 100. She prepared a total of eleven medications for Resident #44 and administered them. When asked if she was preparing the resident's noon medication, she said she was preparing the resident's morning medication. She said she was late for her medications. It was observed that the medications she was preparing were due at 8:00 a.m. and 9:00 a.m. It was also observed that the resident's eMAR was in red. During an interview on 06/14/2026 at 11:57 a.m., MA D said since Resident #44's medications were late, it could be considered a medication error. She said the resident's eMAR was red implying that the medications were late. During an interview on 06/15/2026 at 8:51 a.m., the DON said she already talked to MA D to ask her why the medications were late and assessed Resident #44. She said the resident was stable and did not have any adverse reactions from the late medications. During an interview on 06/16/2026 at 9:03 a.m., ADON A said she expected all medications to be given within the two-hour window of when the medication is due. For a medication due at 8:00 a.m., it should be given between 7:00 a.m. and 9:00 a.m. For medications scheduled at 9:00 a.m., it should be given between 8:00 a.m. and 10:00 a.m. She said not giving the medications within the time frame would result to medication errors. During an interview on 06/16/2026 at 9:15 a.m., the DON said since the medications were given late, there was a medication error. She said a medication error of 44.4% was a big one and should be corrected. She said medication errors should be prevented to ensure the safety of the residents. She said medication errors, such as wrong time, could cause adverse reactions and worsening of the existing conditions. She said she would find out the root cause of the medication error to identify the causes and implement a fix to the issue observed. She said the expectation was that there was no medication error that would occur. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said medications should be given an hour before or an hour after their due time to prevent medication error. She said medications that were due at 8:00 a.m. and 9:00 a.m. and were given at almost noon were unacceptable. She said she would coordinate with the DON about the issue. Record review of the facility's policy Drug Administration Operational/Resident Care Policies, undated, reflected The facility will ensure that medication error rates are not 5 percent or greater and the residents are free of any significant medication errors . All drug errors and adverse drug reactions will be reported to the resident's physician in a timely manner, as warranted by an assessment of the resident's condition, and recorded in the resident's record . Drug administration in error can occur in several instances . the drug is administered at the wrong time. Record review of the facility's policy Medication Errors and Drug Reactions undated, reflected Purpose . 5. To report when a drug is not given at the correct time.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two of ten residents (Resident #44 and Resident #113) reviewed for medication administration. 1.The facility failed to ensure MA D administered Resident #44's medication on time on 06/14/2026. 2.The facility failed to dispose of Resident #113's expired insulin on 06/15/2026. These failures could place residents at risk of not receiving the full therapeutic benefits of the medications and not receiving medications as ordered resulting to adverse effects.Findings included: 1.Record review of Resident #44's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with dementia (a condition characterized by loss of memory and ability to reason), pleural effusion (collection of fluid around the lungs), drug induced constipation (problem with passing stool), GERD (stomach acid flows back into the tube connecting your mouth and stomach), rheumatoid arthritis (inflammation of the joints), hypertension (high blood pressure) and anxiety (intense or excessive fear or worry). Record review of Resident #44's Comprehensive MDS Assessment, dated 04/08/2026, reflected the resident had a severe impairment with cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated the resident had medically complex conditions. Record review of Resident #44's Comprehensive Care Plan, dated 05/28/2026, reflected the resident was at risk of complications and one of the interventions was administer medications at the same time of the day.Record review of Resident #44's Physician Order, dated 04/25/2026, reflected Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by mouth one time a day for GERD. The medication was scheduled to be administered at 9:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema (swelling caused by fluid trapped in the tissues of the body). The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Lidocaine External Patch 4 % (Lidocaine) Apply to AFFECTED AREA topically one time a day for Pain and remove per schedule. The patch was scheduled to be applied at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Losartan Potassium 50 MG Tablet Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . HOLD If SBP less than 100 or DBP less than 60 IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Metoprolol Succinate ER Oral Tablet Extended-Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . HOLD If SBP less than 100 or DBP less than 60 OR PULSE less than 60. IF SBP > 180 or DBP > 110 NOTIFY NURSE/PHYSICIAN. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350). Give 17 grams by mouth one time a day for STOOL SOFTENER. Give 1 scoop (=17gm) mixed in 6-8 oz of fluid. Document amount taken. The Miralax was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 04/25/2026, reflected Paroxetine HCl Oral Tablet 30 MG (Paroxetine HCl) Give 1 tablet by mouth one time a day related to OTHER SPECIFIED DEPRESSIVE (persistent feeling of sadness or loss of interest) EPISODES. The medication was scheduled to be given at 9:00 a.m. Record review of Resident #44's Physician Order, dated 04/29/2026, reflected Hydroxychloroquine Sulfate Tablet 200 MG Give 1 tablet by mouth two times a day related to RHEUMATOID ARTHRITIS, UNSPECIFIED . for 90 Days. The medication was scheduled to be given at 9:00 a.m. Record review of Resident #44's Physician Order, dated 03/17/2026, reflected Senna Oral Tablet 8.6 - 50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth two times a day for Constipation. The medication was scheduled to be given at 8:00 a.m. Record review of Resident #44's Physician Order, dated 03/16/2026, reflected Ipratropium Bromide Nasal Solution 0.06% (Ipratropium Bromide [Nasal]) 2 sprays in both nostrils three times a day for Rhinorrhea (runny nose). The medication was scheduled to be given at 8:00 a.m. During an observation and interview on 06/14/2026 at 11:37 a.m., revealed MA D was passing medications in hall 100. She went inside Resident #44's room and took the resident's blood pressure. After taking the resident's blood pressure, she started to prepare the resident's medications. When asked if she was preparing the resident's noon medication, she said she was preparing the resident's morning medication. She said she was late for her medications. It was also observed that the resident's eMAR was red. During an interview on 06/14/2026 at 11:57 a.m., MA D said aside from the residents' complaining that their medications were late, it might affect the overall health of the residents because the medications were late. She said the right procedure for passing medications was to administer them one hour before and one hour after. She said the resident's eMAR was red implying that the medications were late. During an interview on 06/15/2026 at 8:46 a.m., LVN C said he was not aware that MA D was late for the medications. He said he had no idea why she was late. He said he passed some of the residents' medication in hall 100. He said the health of the residents might be affected like their condition was not improving because of the late medication. During an interview on 06/15/2026 at 8:51 a.m., the DON said she was not aware that MA D was late with her medications. She said she would talk to MA D and assess Resident #44. 2.Record review of Resident #113's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus. Record review of Resident #113's Comprehensive MDS Assessment, dated 05/06/2026, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus and was receiving insulin. Record review of Resident #113's Comprehensive Care Plan, dated 05/04/2026, reflected the resident had diabetes mellitus and one of the interventions was administering diabetes medication as ordered. Record review of Resident #113's Physician Order, dated 02/26/2026, reflected Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 180 = 0 units < 70 give OJ; 181 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units > 401. give 12 units and call MD, recheck in 15 minutes, subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. During an observation on 06/16/2026 at 12:28 p.m. revealed Resident #113's insulin was inside the medication room's refrigerator, along with the other insulins. The insulin was opened on 05/15/2026. During an interview on 06/16/2026 at 12:29 p.m., RN B said the insulin was already expired because the shelf life for Humalog was 28 days. She said she did not know who left the expired insulin inside the refrigerator. She said the insulin should have been disposed of and not left inside the refrigerator along with the other insulin because somebody might have used the expired insulin accidentally. She said expired medications could be less effective or more toxic. During an interview on 06/16/2026 at 9:03 a.m., ADON A said there should not be expired medication inside the medication room's refrigerator because expired medications could be less potent and would not be able to provide the full benefit of the medications. She said the nurses were responsible for ensuring there were no expired medications in the refrigerator. She said, maybe a nurse took a new insulin but was not able to dispose of the expired one. She said medications could be administered one hour before and one hour after. She said medications should be administered on time to meet the needs of the residents. She said she would coordinate with the DON about the issue. During an interview on 06/16/2026 at 9:15 a.m., the DON said they inspected all the carts and medication rooms the night before. She said she did not know why there was an expired insulin inside the medication room. She said, maybe a nurse was getting a new insulin and accidentally left the expired insulin. She said the expired insulin should have been disposed of. She said there was a time frame for each hall to administer the medications. She said some of the residents were assigned to the nurses to ease the load of the MAs, so she could not understand why the medications were administered very late. She said she will do an in-service about making sure there were no expired medications and medication administration. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said she was not a clinician and would let the DON take the lead about the expired medication and late medication administration. Record review of the facility's policy Pharmacy Services Operational/Resident Care Policies, undated, reflected The facility provides routine and emergency drugs and biologicals to residents . The facility uses an automated dispensing machine called Omnicell to ensure the safe, and accurate dispensing of medications . The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of the resident . When pharmacy services are provided . the facility assumes responsibility for obtaining services that meet professional standards, principles, and timeliness of the service. Record review of the facility's policy, Drug Security Operational/Resident Care Policies, undated, reflected, The facility establishes procedures for storing and disposing of drugs and biological . Medications . medications which have passed the expiration date . will be stored separately under lock andkey in the director of nurses' office and in the medication room. Policy for insulin shelf life requested on 06/16/2026 at 12:55 p.m. via email to the Administrator. The Administrator replied, via email, they do not have a policy regarding the shelf life of insulins but would follow the manufacturer's guideline.

Based on observation, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one of eight residents (Residents #13) reviewed for accuracy of assessments. The facility failed to ensure Resident #13's Comprehensive MDS Assessment, dated 05/01/2026, accurately reflected that the resident was receiving insulin. This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.Findings included: Record review of Resident #13's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar). Record review of Resident #13's Comprehensive MDS Assessment, dated 05/01/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus but did not indicate that the resident was receiving insulin. Record review of Resident #13's Comprehensive Care Plan, dated 04/14/2026, reflected that the resident had diabetes mellitus and one of the interventions was to administer diabetes medication as ordered. Record review of Resident #13's Physician Order, dated 05/08/2026, reflected Trulicity Subcutaneous Solution Autoinjector 0.75 MG/0.5ML (Dulaglutide) Inject 0.75 mg subcutaneously (administer under the skin) one time a day every Fri related to . TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. During an observation and interview on 06/16/2026 at 8:57 a.m., MDS Nurse H said if a resident was receiving insulin, then the resident should be coded that she was receiving hypoglycemic (medications used to lower high blood sugar) medications. She went to Resident #13's MDS and saw that the resident was not coded for hypoglycemic medications. She then changed the code, so the MDS would reflect that the resident was on hypoglycemic medication. She said it was an oversight on her part. She said the MDS captures the care that a resident needed. She said the MDS was a form of a clinical assessment to determine the needs of the residents. She said if the assessment was not accurate, then there could be a probability that the needs would not be met. She said she would also audit the MDS of the other residents. During an interview on 06/16/2026 at 9:03 a.m., ADON A said she was not familiar with the MDS but if the MDS needed to reflect that residents were being administered hypoglycemic medications, then it should be in the MDS. During an interview on 06/16/2026 at 9:15 a.m., the DON said the MDS painted the picture of the needs of the residents so that appropriate care could be implemented. She said the MDS could also be used to do the care plan. She said she would coordinate with the MDS Nurse to do an audit. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said she was not familiar with MDS and would coordinate with the MDS Nurse and the DON about the issue. Record review of the facility's policy Resident Assessment Operational/Resident Care Policies, undated, reflected It is the policy of this facility to conduct and document, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a resident's functional capacity on all residents admitted to the facility . This will provide the facility with the information necessary to develop a care plan and to provide appropriate care and services for each resident.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of eighteen residents (Resident #24) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #24's room was in a position that was accessible to the resident on 06/14/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Record review of Resident #24's Face Sheet, dated 06/16/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Record review of Resident #24's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/26/2026, reflected the resident had a severe (resident required significant assistance and support in daily life) impairment in cognition with a BIMS (screening tool used to assess cognitive status) score of 03. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer, toileting, hygiene, shower, and dressing. Record review of Resident #24's Comprehensive Care Plan, dated 03/23/2026, reflected the resident had a history of falling and was at increased risk of falling and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 06/14/2026 at 9:08 a.m., Resident #24 was in his bed, awake. It was observed that the resident's call light was on the floor. When asked what he used when he needed assistance, the resident shrugged his shoulders. During an observation and interview on 06/14/2026 at 9:10 a.m., CNA E said call lights should always be within reach of the residents because that was how they called the staff if they needed something. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She went inside Residents #24's room and saw the call light on the floor. She pulled the call light from the floor and put it where the resident could reach it. She said, maybe, the call light fell when the resident was repositioned. She said the staff who repositioned him should have made sure the call light was within the resident's reach before leaving the resident's room. During an interview on 06/15/2026 at 8:46 a.m., LVN C said he heard about Resident #24's call light. He said he did not notice that the resident's call light was on the floor. He said staff should always make sure the call lights were with the resident before leaving the room so that they could call the staff if they needed anything. During an interview on 06/16/2026 at 9:03 a.m., ADON A said the call lights should always be with the residents or within reach of the residents. She said the staff should make sure that the call lights were with the residents before they leave the room. She said the call lights were for all residents, regardless of whether they were dependent or independent. She said all the staff were responsible in making sure the call lights were with the residents. She said the expectation was for the staff to make sure that all the call lights were within reach of the residents. She said she would coordinate with the DON regarding the call lights. During an interview on 06/16/2026 at 9:15 a.m., the DON said call lights were inside the residents' rooms so they can call the staff for assistance, a glass of water, pain medication, or if they needed to be changed. She said if the call lights were not within reach, their needs would not be met. She said the call lights were for all the residents, and all the staff were responsible for the call lights. She said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensure the call lights were within reach of the residents before they left the rooms. She said she would start an in-service about call light placement. During an interview on 06/16/2026 at 9:41 a.m., the Administrator said call lights should always be within the reach of the residents. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents might fall trying to get up to get what they needed. She said she would collaborate with the DON about the issue regarding call lights. Record review of facility's policy Call Lights undated, reflected Purpose: To respond to a resident's call light for their needs . 9. The call light must always be within resident's reach before you leave the room.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #2) of five residents reviewed for respiratory care.The facility failed to ensure Resident #2 's breathing mask was stored properly when not in use on 02/17/2026.This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #2's Face Sheet, dated 02/17/2026, reflected a [AGE] year-old female who admitted on [DATE]. She had diagnoses which included COPD (lung disease that obstructs airflow from the lungs) and acute and chronic respiratory failure with hypoxia (the lungs cannot get enough oxygen to your blood). Record review of Resident #2's Entry MDS Assessment, dated 02/06/2026, did not include Section C (Cognitive Patterns) or the resident's acts of daily living needs. Record review of Resident #2's 5-Day MDS Assessment, dated 02/13/2026, was in progress and Section C was not completed. Section O (Special Treatments, Procedures, and Programs) indicated Resident #2 received physical therapy and occupational therapy. Record review of Resident #2's Comprehensive Care Plan, dated 02/09/2026, reflected the resident had chronic obstructive pulmonary disease. An intervention, added 02/17/2026, was to provide nebulizer treatments as ordered. Record review of Resident #2's Physician Order, dated 02/16/2026, reflected Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 unit inhale orally via nebulizer four times a day related to ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA for 7 days.During an observation on 02/17/2026 at 10:08 AM, Resident #2 was lying in bed asleep. A nebulizer was observed on her nightstand. The attached breathing mask was not in a bag. During an interview on 02/17/2026 at 10:10 AM, CNA C stated the nurse monitored the nebulizer mask. She stated if the nurse forgot, she could get a bag to put the mask in. She stated she notified the nurse if a resident removed the nebulizer mask before completing the breathing treatment. She stated if it was on the floor, she would throw it away and tell the nurse so she could get a new one. She stated it was important to keep the nebulizer mask sanitary for infection control. During an interview on 02/17/2026 at 10:17 AM, RN B stated Resident #2's nebulizer mask should have been in a bag. She stated it was important to ensure nebulizer masks were stored in a bag and dated. She stated it was to help prevent infection. During an interview on 2/18/26 at 10:32 AM, ADON A stated the expectation was for oxygen tubing and all respiratory masks to be bagged. He stated Resident #2's nebulizer mask should have been stored in a bag because that was part of infection control. He stated the resident had a new order for breathing treatments He stated the nurses were responsible for ensuring the nebulizer mask was placed in a bag after the resident completed a breathing treatment. During an interview on 2/18/2026 at 10:48 AM, the Administrator stated Resident #2's nebulizer mask should have been in a bag. She stated nurses should be monitoring the nebulizer masks. She stated it was important for infection control. During an interview on 2/18/2026 at 11:04 AM, the DON Resident #2's nebulizer mask should have been in a bag. She stated nurses put on and take off nebulizer mask and were responsible for ensuring they were put in a bag after a treatment. She stated it was important to prevent infection. The facility did not have a policy specifically related to the storage of respiratory items when not in use.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #39, Resident #50 and Resident #219) of fifteen residents reviewed for Infection Control. 1. The facility failed to ensure the Wound Care Nurse performed hand hygiene when changing gloves during wound care for Resident #39 on 05/05/2025. 2. The facility failed to ensure CNA K did not take a bedside table from Resident #50's room into the hall with contaminated linens on the bedside table on 05/05/2025. 3. The facility failed to ensure CNA B performed hand hygiene, changed gloves, and wore a gown while performing Resident #219's incontinent care on 05/05/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #39's Face Sheet, dated 05/06/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included local infection of the skin and subcutaneous tissue (deepest layer of the skin), hypertension (high blood pressure), and chronic kidney disease (gradual loss of kidney function). Record review of Resident #39's Quarterly MDS Assessment, dated 04/22/2025, reflected moderately impaired cognition with a BIMS score of 10. The MDS Assessment reflected Resident #39 was administered an antibiotic for a wound infection. Record review of Resident #39's Comprehensive Care Plan, dated 04/17/2025, reflected Resident has skin INJURY to ABDOMEN. One intervention was to Follow house protocol/regime for treating breaks in skin integrity/pressure ulcers. Record Review of Resident #39's Physician Order, dated 04/21/2025, reflected to clean the wound bed on the abdomen with wound cleanser or normal saline and pat dry. Apply Santyl (medicated ointment) to the wound bed, silver alginate (antimicrobial wound dressing), and cover with a dry dressing one time a day. During an observation and interview on 05/05/2025 at 11:05 AM, the Wound Care Nurse stated Resident #39 was admitted with a left abdominal wound. There was a disposable barrier pad placed on top of the bedside table and the wound care supplies were on the barrier pad. The Wound Care Nurse told Resident #39 she was going to change the wound dressing and asked if the resident had any pain. The Wound Care Nurse pulled the privacy curtain around the resident's bed and washed her hands in the resident's restroom. The Wound Care Nurse cleaned the wound with saline and dropped the gauze into a bag. The Wound Care Nurse removed her gloves and did not use hand sanitizer before putting on clean gloves. She used a q tip to remove the Santyl ointment from a small plastic container and applied it to the wound bed. She applied the silver alginate to the wound bed and covered it with a bandage. The Wound Care Nurse tied up the bag of trash, cleaned the table, and washer her hands in the resident's restroom. She stated she should have used hand sanitizer when she changed her gloves. She stated she had a bottle of hand sanitizer in her treatment cart but forgot to take it into the room with her. She stated it was important to use hand sanitizer after removing soiled gloves to prevent the spread of infection. During an interview on 05/05/2025 at 1:50 PM, the DON stated the Wound Care Nurse should have sanitized her hands between glove changes. She stated it was important to avoid transmission of any type of bacteria or infectious disease. 2. Record review of Resident #50's Face Sheet, dated 05/06/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cerebral infarction (interruption of blood flow to the brain). Record review of Resident #50's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 02/01/2025, reflected moderately impaired cognition with a BIMS (screening tool used to assess cognitive status) score of 10. Section G (functional status) indicated Resident #50 required extensive assistance with acts of daily living. Section I (active diagnoses) indicated Resident #50 was treated for pneumonia (lung infection). Record review of Resident #50's Comprehensive Care Plan, dated 02/17/2025, reflected the resident was incontinent of bladder related to physical and mental decline. One intervention was to monitor for signs and symptoms of a urinary tract infection which included an elevated temperature, difficulty urinating, and blood in the urine. During an observation and interview on 05/05/2025 at 8:40 AM, CNA I and CNA K provided incontinence care for Resident #50. Incontinence care items were on a bedside table in Resident #50's room. The bedside table was brought into the room and did not belong to Resident #50. A towel was draped over the top of the bedside table and incontinence care supplies were on the towel. Resident #50's curtain was pulled around her bed for privacy. CNA I and CNA K washed their hands in the resident's restroom. CNA I pulled down the front of the brief and cleaned the resident using a single wipe for each pass. CNA I removed her gloves and used hand sanitizer before putting on clean gloves. CNA K assisted CNA I to turn Resident #50 to her left side. CNA I removed her gloves and used hand sanitizer before putting on clean gloves. CNA I wiped Resident #50's bottom using a single wipe for each pass. CNA I removed her gloves and used hand sanitizer before putting on clean gloves. CNA I placed a clean brief under Resident #50 and secured the tabs on the brief. CNA I removed her gloves and used hand sanitizer before putting on clean gloves. CNA K assisted CNA I to pull up the resident's pants. CNA I bagged the soiled items. CNA I and CNA K removed their gloves and washed their hands in the resident's restroom. CNA I took the bagged items across the hall to dispose of them. CNA K took the bedside table into the hall and placed it against the wall outside of Resident #50's room. The bedside table had the towel draped over the top and an unused towel on it. When asked about it, CNA K stated she should not have brought the bedside table into the hall with supplies on it. She stated she should have bagged the linens on the bedside table before bringing the bedside table into the hall. She stated after taking the linens into the resident's room, they were contaminated. CNA I agreed the linens should have been bagged in Resident #50's room and not brought into the hall on the bedside table. She stated it was important to avoid bringing contaminated items out of a resident's room to prevent the spread of infection. During an interview on 05/05/25 at 10:15 AM, ADON J stated the towels should have been removed from the bedside table and bagged for laundering. She stated they should not have been brought into the hall on the bedside table. She stated it was important to prevent cross-contamination. During an interview on 05/05/2025 at 11:21 AM, RN L stated the towels should have been bagged in the resident's room. RN L stated regardless of if they were used or not, they must be bagged and taken to the soiled linen room. She stated it was important to prevent contamination and the spread of infection to staff and to other residents. She stated she would follow up with the CNAs. During an interview on 05/05/25 at 1:50 PM, the DON stated her expectation was for staff to contain all soiled items before leaving a resident's room. She stated the towels were contaminated, after taking them into the resident's room, and should have been bagged before removing them. The DON stated it was important to avoid transmission of any type of bacteria. She stated staff would be in-serviced. 3. Review of Resident #219's Face Sheet, dated 05/05/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with cystitis (inflammation of the urinary bladder) with hematuria (blood in the urine). Review of Resident #219's Comprehensive MDS Assessment, dated 04/11/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09 (resident may need additional support and monitoring). The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Review of Resident #219's Comprehensive Care Plan, dated 04/14/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was perennial care after each incontinent episode. The Comprehensive Care Plan indicated that the resident also had a skin breakdown to right buttocks. Observation on 05/05/2025 at 9:19 AM revealed CNA B went inside Resident #219's room to answer a call light. Once inside the room, he asked the resident what she needed. A family member, who was inside the room, said the resident needed to be changed. CNA B told the family member that he would go ahead and change the resident. He put on a pair of gloves and proceeded with incontinent care. He did not wash his hands before doing incontinent care. Before doing the process, he took the trash can from the other side of the bed and put it beside him. He then changed his gloves but did not sanitize his hands before putting on a new pair of gloves. He unfastened the brief on both sides and pushed it between the legs. He then pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. He did it four times. After cleaning the perineal area, he instructed and assisted the resident to roll towards the left side, and cleaned the resident's bottom. After cleaning the resident's bottom, he pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, he took the brief from the resident's side table, placed it beneath the resident, and fixed it. He instructed the resident to roll to the other side so he could fix the other half of the brief. After fixing the brief, CNA B rolled back the resident and fastened the brief on both sides. He did not change his gloves after cleaning the resident's bottom and before touching the new brief. After he was done with incontinent care, he gathered his trash and left the room to throw his trash on the utility room. He did not wash his hands after performing incontinent care. A sign outside the room indicated that the resident was on enhanced barrier precaution. CNA B did not wear a gown while providing incontinent care. In an interview and observation on 05/05/2025 at 9:26 AM, CNA B stated hand hygiene was important to prevent cross contamination and development of infection. He said he was not able to wash his hands before and after doing Resident #219's incontinent care. He said during the process, he should had sanitized his hands after he changed his gloves and should had changed his gloves after cleaning the resident's bottom. He said his actions could cause transfer of germs and possible infection. He said he would be mindful the next time he would perform incontinent care. CNA B then saw the sign outside the resident's room and realized that the resident was on enhanced barrier precaution. He said he did not notice the sign and he was used to of having the PPE cart outside the room of the resident if they were on enhanced barrier precaution. CNA B then saw the gown inside the resident's room near the resident's restroom. He said, next time, he would check if the resident was on enhanced barrier precaution before entering the resident's room. In an interview on 05/05/2025 at 12:19 PM, ADON A stated staff must wash their hands before and after incontinent care. She said staff should be mindful that when they touched something dirty, they should change their gloves before touching something clean. She also said that before putting on a new pair of gloves, staff must wash their hands or sanitize their hands depending how soiled the resident was. She said if the resident had a sign outside the door that said enhanced barrier precautions, staff must wear a gown to prevent the spread of any unwanted microorganism. She said she would coordinate with the DON to do an in-service pertaining to hand hygiene, infection control, and enhanced barrier precaution. In an interview on 05/05/2025 at 2:20 PM, the DON stated hand hygiene was the most efficient way to avoid cross contamination and development of infection. She said staff should do hand hygiene before and after any care, should sanitize their hands when changing gloves, and change their gloves after touching anything soiled. All of these should be done to make sure that microorganisms would not transfer to the clean items. She also said that if a resident was on enhanced barrier precaution, the staff should wear a gown when caring for them. She said Resident #219 had a wound at the bottom, which was why she was on enhanced barrier protection. She said she was responsible in overseeing that the staff were following the policies and procedure for infection control. She said the expectation was for the staff to follow the protocols for infection control and hand hygiene. She said she would personally monitor the staff's adherence to the policy and procedure of infection control, enhanced barrier protection, and hand washing. In an interview on 05/06/2025 at 8:52 AM, the Administrator stated that staff must be mindful in preventing spread of germs and development of infection. He said he was not a clinician and would let the DON take the lead in educating the staff about infection control, hand washing, and enhanced barrier precaution. Record review of the facility's Incontinent Care Procedure and Proficiency Evaluation undated, revealed Perineal Care . 7. Perform hand hygiene, don gloves . 11. Remove soiled pad and clothing and place in plastic bag . 12. Remove gloves and discard .13. Preform hand hygiene, don gloves . 14. Place clean pad under resident . 22. Dispose of soiled linens, trash appropriately . 22. Preform hand hygiene. Record review of the facility's policy Hand Washing undated, revealed Policy: Hand washing is required before and after a procedure that involves direct or indirect contact with a resident. Record review of the facility's policy Enhanced Barrier Precautions (EBP) revealed EBP are indicated for residents with: . Wounds . even if resident is not known to be infected. Review of the facility's policy Linens reflected Soiled linen and clothing will be transported in accordance with procedures consistent with universal precautions. Bags or containers will not be reused to transport or store clean items. The staff should handle all used laundry as potentially contaminated. Review of the facility's policy Infection Control Program reflected All employees are required to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine and ice scoop holder in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure prepared food in the refrigerator was labeled and dated when stored. 5. The facility failed to ensure expired food in the refrigerator was discarded. 6. The facility failed to ensure kitchen and dining room equipment was cleaned and sanitized. 7. The facility failed to ensure foods stored in the freezer was sealed from air-borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on [DATE] from 9:05 AM to 9:15 AM in the facility's only kitchen revealed: The ice machine, located in the kitchen had black and white stains on the inside of the machine and along the opening of the machine. The ice scoop holder, hanging on a wall near the ice machine, had gritty stains inside the bottom of the holder. One ice machine, located in the dining area, had built up dark brown dirt along the area where a black tray was positioned. One ice cream machine, located in the dining area, had white and brownish stains plastered all over the outside of it. One bowl of chef salad, located in a refrigerator, was not labeled with the date it was stored. One large container of fruit cocktail, located in the refrigerator, had a use by date of [DATE], and was not discarded. Three large bags of pre-scrambled eggs, located in the refrigerator, was not labeled with the date the items were stored. One pack of cheese wrapped in a clear wrap, located in the refrigerator, was not labeled with the date the item was stored. One large cooking container of soup, located in the refrigerator, was not labeled with the date the item was stored. One large tea dispenser, located in the dining area, had tea filled to the top of it and it did not have a lid placed on the top of the dispenser to avoid air-borne contaminants. One large tray of frozen beef patties, located in the freezer, had a sheet of foil laying on top of the tray and it was not sealed from air-borne contaminants. One plate containing fruits, cottage cheese, lettuce, and crackers, located in a refrigerator, was not labeled with the date it was stored. In an interview on [DATE] at 1:05 PM, the Dietary Manager was shown pictures of the concerns observed in the kitchen area on [DATE]. She stated the tea dispenser should have been covered once it was done. She stated the ice machine, ice cream machine, and ice scoop holder was cleaned at night at the end of the day and she checked for cleanliness when she arrived in the morning. She stated the items not dated should have been dated once stored, and items should have been discarded once it had passed the use by date. She stated the frozen beef patties should have been sealed properly when stored. She stated all the concerns observed could result in cross contamination and air-borne contaminates. In an interview on [DATE] at 9:53 AM, the Administrator was shown pictures of the concerns observed in the kitchen and dining area. He stated he expected these areas to comply and meet all expectations. He stated the risk of the concerns not being addressed could result in food contamination. Record review of the facility's policy on Operational/Resident Care Policies(undated), revealed Food is store, prepared, distributes, and served to residents in accordance with professional standards for food safety. Leftovers should be discarded after 72 hours. Freshness dates on refrigerated products should be checked and discarded if warranted.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 8 residents (Residents #49, #55, and #61) reviewed for accident prevention. 1. The facility failed to ensure Resident #49, #55, and #61 had physician orders for the for the scoop mattress on their bed. 2. The facility failed to ensure CNA E used a gait belt when transferring Resident #55 from bed to wheelchair on 05/05/2025. These failures could prevent the residents from having an environment that was free and clear of accidents and hazards. Findings include: 1. Record review of Resident #49's Face Sheet, dated 05/04/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included history of falls and need for assistance of personal care. Record review of Resident #49's Quarterly Minimum Data Set (MDS) assessment, dated 04/15/25, reflected she had a BIMS score of 7 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance. For active diagnosis, it reflected unstadiness on his feet. Record review of Resident #49's Comprehensive Care Plan, dated 04/07/25, revealed the resident had a history of fall and there was no mentioning of using a scoop mattress as an intervention. Record review of Resident #49's physician orders, dated 05/04/25, reflected no physician orders for the scoop mattress. An Observation on 05/04/25 at 11:58 AM, revealed Resident #49 had a scoop mattress on her bed. Record review of Resident #55's Face Sheet, dated 05/05/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with multiple fracture of the pelvis, and unsteadiness on her feet. Record review of Resident #55's Quarterly MDS Assessment, dated 04/01/2025, reflected resident had a severe impairment in cognition with a BIMS score of 07. The Quarterly MDS Assessment also indicated the resident needed substantial assistance for transfer. For active diagnosis, it reflected unstadiness on his feet. Record review of Resident #55's Comprehensive Care Plan, dated 03/20/2025, reflected the resident required assistance with activities of daily living and one of the interventions was to provide assistance with transfers, and she had a history of falls. Review of Resident #55's Progress Notes, dated 05/04/2025, reflected the resident was dependent for transfer. Record review of Resident #55's physician orders, dated 04/16/25, reflected no physician orders for a scoop mattress. An observation on 05/04/25 at 12:56 PM, revealed Resident #55 had a scoop mattress on her bed. Record review of Resident #61's Face Sheet, dated 05/04/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included history of falls and lack of coordination. Record review of Resident #61's Quarterly Minimum Data Set (MDS) assessment, dated 04/27/25, reflected she had a BIMS score of 3 (severe cognitive impairment). For ADL care, it reflected the resident required extensive assistance. For active diagnosis, it reflected unspecified fall. Record review of Resident #61's physician orders, dated 05/04/25, reflected no physician orders for the scoop mattress. An Observation on 05/04/25 at 12:35 PM, revealed Resident #61 had a scoop mattress on her bed. In an interview on 05/05/25 at 11:20 AM, ADON A stated Resident #61 was care planned for the scoop mattress, but she did not have physician orders for it. He stated the resident had a history of fall, which was why she was provided the scoop mattress, but he was unaware physician orders were required. He stated the risk of not having physician orders for the resident could result in the resident having an accident as a result of the scoop mattress. In an interview on 05/05/25 at 11:23 AM, ADON K stated Resident #49 did not have physician orders for usage of the scoop mattress. She stated the resident had a history of falls, which was why she was provided the scoop mattress, and she was unsure why the resident had no physician orders. She stated the risk of not having physician orders for the resident could result in the resident having an accident as as result of the scoop mattress and physician orders were required for all specialty equipment. In an interview and observation on 05/05/25 at 12:00 PM, LVN G stated she was the hall nurse for Resident #55. She observed the resident having a scoop mattress on her bed and she stated she was unsure if the resident had physician orders for the mattress. She stated the resident was a fall risk and required the scoop mattress to assist with fall prevention. She stated she was unsure of the risk of the resident not having physician orders for the scoop mattress. In an interview on 05/06/25 at 8:53 AM, the DON stated she had been at the facility more than 4 years. She stated Residents #49, #55, and #61 had assessments and the scoop mattress was not a risk to them. She stated she was not aware that physician orders or a physician assessment was needed for the equipment. She was advised that other residents' record reviews did have physician orders for the scoop mattress. She stated they were working on securing physician orders for the residents to have scoop mattresses. 2. In an observation and interview on 05/05/2025 at 8:17 AM, CNA E stated she would change Resident #55's clothes and then transfer her to her wheelchair because the resident would usually eat better when she was sitting in her wheelchair. CNA E pulled a blouse and pants from Resident #55's cabinet and placed them beside the resident. She washed her hands, put on a pair of gloves, and started to change the resident's clothes. She put on the pants and said she would transfer the resident to her wheelchair and then would put on her blouse. She lowered the bed, placed the resident's wheelchair parallel to the bed, and then assisted the resident to sit at the side of the bed. She told the resident that she was about to transfer her to her wheelchair and the resident started to scoot forward. CNA E then placed her arms under the resident's armpits and lifted the resident to the wheelchair parallel to the bed. CNA E then took off the hospital gown and put on the resident's blouse. CNA E did not use a gait belt during transfer. In an interview on 05/05/2025 at 8:40 AM, CNA E stated she transferred Resident #55 using a stand and pivot technique. She said the resident provided little assistance during the transfer. She said a gait belt was required if a resident was transferred manually and she knew she needed a gait belt to transfer Resident #55 but did not find one inside the room. She said she should had looked for a gait belt first before proceeding with the transfer. She said a gait belt was required during transfer to ensure the safety of the resident. In an interview on 05/05/2025 at 8:49 AM, LVN G stated staff should use a gait belt when a resident was being transferred to a wheelchair to protect the resident and the back of the staff as well. She said if there was no gait belt inside the resident's room, the staff should have asked or looked for one before transferring the resident. Observation on 05/05/2025 at 9:35 AM revealed LVN G was distributing gait belts to some of the resident's room. In an interview on 05/05/2025 at 12:19 PM, ADON A stated a gait belt was needed when transferring a resident to a wheelchair to avoid injury to the resident and the staff. She said the purpose of a gait belt was to prevent falls of weak residents or those who were high risk for fall. She said the expectation was for the staff to transfer the residents using a gait belt. She said they should use the gait belt when transferring a resident from bed to wheelchair and wheelchair to bed. She said she would coordinate with the DON in educating the staff with regards to proper transfer. In an interview on 05/05/2025 at 2:20 PM, the DON stated the staff must use a gait belt if they were transferring a resident from bed to wheelchair and wheelchair to bed. She said the gait belt was used to maintain stability and support during manual transfer. She said the staff would place the gait belt around a resident's waist snugly so they would have a secure grip to prevent slips and falls. She said the expectation was for the staff to transfer the residents using a gait belt to ensure a safe transfer and that she would monitor the issue closely to avert any accidents during transfer. In an interview on 05/06/2025 at 8:52 AM, the Administrator said the staff must use a gait belt during transfer because if a resident fell during the process of transfer, the staff will not have anything to grab. He said the expectation was for the staff to make sure there were gait belts inside the residents' room who needed gait belt during transfer and to use the gait belt to ensure the residents were safe during transfer. He said he would coordinate with the DON to in-service the staff pertaining to transfer. Record review of facility policy, Transfer of Patient undated, revealed Purpose: To safely move resident from one place to another . Equipment: 1. Gait belt . Procedure . 5. Help resident to sit on edge of the bed with legs and feet hanging over the edge . 6. Stand in front of the resident with a firm grasp on gait belt that has been secured around resident waist. The facility's policy Restraint Free Facility Initiative (undated) reflected It is the policy of this facility to not restrain residents, chemically or physically, except for their own safety or to prevent harm to other residents. The facility recognizes that restraints may constitute an accident hazard.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #1, Resident #11, and Resident #42) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was care planned for hospice on 05/04/2025. 2. The facility failed to ensure Resident #11's was care planned for Parkinson's Disease (a movement disorder). 3. The facility failed to ensure Resident #42's was care planned for Parkinson's Disease. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: 1. Record review of Resident #1's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with encephalopathy (a condition that caused brain dysfunction), respiratory failure, kidney disease, and cerebrovascular disease (stroke). Record review of Resident #1's Quarterly MDS Assessment, dated 04/17/2025, reflected the resident had severe impairment in cognition with a BIMS score of 07 (resident required significant assistance and support in daily life). The Quarterly MDS Assessment indicated the resident was receiving hospice care. Record review of Resident #1's Comprehensive Care Plan, dated 04/18/2025, reflected the resident did not have a care plan for hospice care. Record review of Resident #1's Physician Order, dated 04/07/2025, reflected HOSPICE - ADMIT . HOSPICE for DX: Sequalae (complications resulting from previous disease or injury) of unspecified cerebrovascular disease. In an interview and observation on 05/04/2025 at 9:17 AM revealed the resident was in his bed with eyes closed. A family member was at bedside and said she was notified that Resident #1 had a change of condition and was declining. In an interview on 05/04/2025 at 10:42, Hospice Nurse M stated Resident #1 was actively dying and she was there to give additional orders to keep the resident comfortable. She said she already gave RN F the new orders. 2. Record review of Resident #11's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's Disease (movement disorder). Record review of Resident #11's Quarterly MDS Assessment, dated 04/03/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that Parkinson's disease was one of the resident's primary medical conditions. Record review of Resident #11's Comprehensive Care Plan, dated 03/23/2025, reflected the resident did not have a care plan for Parkinson's disease. Record review of Resident #11's Physician Order, dated 01/30/2025, reflected Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day related to PARKINSON'S DISEASE WITHOUT DYSKINESIA (difficulty in controlling movements), WITHOUT MENTION OF FLUCTUATIONS (changes in the ability to move). 3. Record review of Resident #42's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's Disease. Record review of Resident #42's Quarterly MDS Assessment, dated 03/26/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11 (resident may need additional support and monitoring). The Quarterly MDS Assessment indicated that Parkinson's disease was one of the resident's primary medical conditions. Record review of Resident #42's Comprehensive Care Plan, dated 04/18/2025, reflected the resident did not have a care plan for Parkinson's disease. Record review of Resident #42's Physician Order, dated 01/01/2025, reflected Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day related to PARKINSONISM. In an interview and observation on 05/05/2025 at 10:55 AM, the MDS Nurse stated a care plan is a reflection of a resident's care and services being provided by the staff. She said it indicated the observations done by the staff to be able to provide the best care possible. She said if there was no care plan, the staff might miss something and the residents' needs will not be addressed. She said if a resident was admitted in hospice, there should be a care plan for hospice to make sure the resident was comfortable and given a proper end of life care. She said if a resident had a diagnosis of Parkinson's, there should be a care plan for Parkinson's just like there was a care plan for hypertension, diabetes, and heart failure. She logged on to her computer and saw that Resident #1 was on hospice, had an order for hospice admission, and was coded for hospice. She said she missed it and started adding the care plan for hospice. She then checked Resident #11 and Resident #42's profile and saw both residents had Parkinson's disease as a diagnosis, were taking carbidopa, and were coded for Parkinson's as one of their primary medical conditions. She said she would also add a care plan for Parkinson's for Residents #11 and #42. She said she would also check the MDS of the other residents to check if she missed something. She said care plan were done quarterly, annually, and when there was a change in condition. In an interview on 05/05/2025 at 12:19 PM, ADON A stated everything about the resident should be care planned to make sure the residents were being taken care for and so that the staff were in sync with the care being provided to the residents. She said without the care plan, needed interventions might not be provided. She said the expectation was all the issues of the residents were care planned. She said she would coordinate with the DON and the MDS Nurse on how to make sure the residents were care planned accordingly. In an interview on 05/05/2025 at 2:20 PM, the DON stated every resident needed a comprehensive care plan to ensure the residents received the care needed and appropriate to their current conditions and functionality. She said the care plans reflect the resident's problem lists, the goals, and the interventions. She said care plans should be in place so all the staff providing care would be on the same page. She said without the care plan, there could be confusion with the care needed by the residents. she said if a resident had a change in condition and was admitted to hospice, the care plan for hospice should be added. She said if residents had Parkinson's, then there should be a care plan for their Parkinson's disease. She said the expectation was every resident had detailed care plans and they should be reflected on their profile. She said she would coordinate with the MDS Nurse to audit the care plans of the residents. In an interview on 05/06/2025 at 8:52 AM, the Administrator stated all the care, services, and treatment done for the residents should be reflected in their care plans to make sure the staff would not know and understand what kind of care to provide. He said he was not a clinician and would let the DON take the lead in making sure the residents had their care plans in place. Record review of the facility's policy, Comprehensive Person-Centered Resident Care Planning, undated, Operational/Resident Care Policies revealed A comprehensive person-centered care plan is developed and implemented for each resident . will incorporate resident-centered goals . to meet a resident's medical, nursing, and mental and psychosocial needs.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #42 and Resident #93 ) of eighteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #42 and #93's rooms were in a position that was accessible to the resident on 05/04/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #42 Record review of Resident #42's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with lack of coordination and gait abnormalities. Record review of Resident #42's Quarterly MDS Assessment, dated 03/26/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11 (resident may need additional support and monitoring). The Quarterly MDS Assessment indicated the resident required extensive assistance for bed mobility and transfer. Record review of Resident #42's Comprehensive Care Plan, dated 04/18/2025, reflected the resident had a history of falling and one of the interventions was to be sure the resident's call light was within reach. In an interview and observation on 05/04/2025 at 9:22 AM revealed Resident #42 was sitting in his wheelchair inside his room. It was observed that the resident's call light was between the mattress and the bed frame. When asked where his call light was, the resident just shrugged his shoulders and shook his head. In an observation and interview on 05/04/2025 at 9:49 AM, CNA D stated call lights should be with the residents so they could call the staff if they needed something. She said if the residents were already in their wheelchairs, the call lights should be on top of the bed, or secured on the repositioning bar, or anywhere that could be easily accessed by the residents. CNA D went inside Resident #42's room and observed that the resident's call light was between the mattress and the bed frame. She tried to pull the call light and then said she needed to raise the mattress so she could pull the call light. She raised the mattress, pulled the call light, and placed it on top of the bed. She said staff should make sure the call lights were within reach of the residents before they leave the room so that the needs of the residents could be addressed and also to prevent falls. In an interview on 05/05/2025 at 12:19 PM, ADON A stated the call lights should always be with the residents in case they needed assistance with something like a refill of water or the resident needed a pain medication. She said when a resident was already in the wheelchair, the call light should be on top of the bed so the resident could still call the staff if needed. She said the staff should make sure that the call lights were with the residents before they left the room. She said she would coordinate with the DON to do an in-service about call light placement. In an interview on 05/05/2025 at 2:20 PM, the DON stated call lights were inside the residents' rooms so they can call the staff for assistance, for pain medication, or because they wanted to get up. The DON said if the call lights were not within reach, their needs would not be met and the residents might get upset because there was no way to call the staff. The DON said all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the residents' room when they did their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said she would educate the staff about the importance of call lights for the residents. In an interview on 05/06/2025 at 8:52 AM, the Administrator stated call lights should be with the residents all the time in case they need help. He said the call lights were for all the residents whether dependent or independent. He said the aides where primarily responsible for the call lights but everybody was responsible in making sure the call lights were with the residents to prevent any falls. He said he would coordinate with the DON about the issue regarding call lights. Resident #93 Record review of Resident #93's Face Sheet, dated 05/05/2025, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #93's diagnoses included history of falling, need for assistance with personal care, and dementia (loss of cognitive function that interferes with daily life and activities). Record review of Resident #93's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 02/25/2025, reflected severe cognitive impairment with a BIMS (screening tool to assess cognition) score of 04. Section GG (functional abilities) indicated Resident #93 used a walker to ambulate and required supervision or touch assistance with transfers and walking. Record review of Resident #93's Comprehensive Care Plan, dated 04/24/2025, reflected Resident has a history of falling or other identified risk factors that result in increased risk of falling. One intervention was Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an observation and interview on 05/04/2025 at 11:15 AM, Resident #93 was lying in bed awake. Resident #93's call light was on the floor by the resident's bed. When Resident #93 was asked about her call light, she did not answer. She pointed at her roommate sleeping and then at the door, indicating for the surveyor to leave the room. During an observation and interview on 05/04/25 at 11:29 AM, CNA I stated Resident used the call light at times. She stated it was important to ensure the resident's call light was in reach so staff could be notified when she needed assistance. She stated there were many reasons a resident might need to use their call light. She stated residents needed a way to notify staff in case something happened, or if the resident needed water, pain medication, or needed to go to the restroom. CNA I went to the Resident #93's room and placed the call light on the bed next to the resident and told her to call if she needed anything. During an interview on 05/05/25 at 10:15 AM, ADON J stated the residents' call lights should always be in reach. She stated the call light cord had a clip on it to secure it. She stated whether the resident was in bed or sitting up in a chair, the call light should be placed within reach of the resident. She stated it was important that residents always have access to their call light and be able to reach staff when they need assistance. During an interview on 05/05/25 at 07:50 AM, the DON stated the expectation was to ensure call lights were in reach for residents who were not very mobile. She stated all staff members should ensure the call light is in reach before leaving a resident's room. She stated the call light cords had a clip attached to ensure the call lights were secured and stayed within the resident's reach. She stated it was important for the resident to be able to call staff for assistance. Record review of the facility's policy Resident Call System undated, revealed The nurses' station is equipped to receive resident calls through a communication system from resident rooms at each resident's bedside and at toilet, shower and bathing facilities. The call system shall be accessible to a resident lying on the floor. The call system in resident rooms will be accessible to alert, confined residents and confused residents and the residents will be instructed as to its' availability and location.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #67) reviewed for dignity. The facility failed to ensure staff properly fed Resident #1 breakfast, while he was in bed. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect. Findings include: Record review of Resident #67's face sheet, dated 05/05/25, revealed a 38 -year-old male who was admitted to the facility on [DATE]. Resident #67's relevant diagnoses included Multiple Sclerosis (nerve deterioration), and Idiopathic Peripheral Autonomic Neuropathy (nerve damage). Record review of Resident #67's Minimum Data Set, dated dated [DATE] revealed he had a BIMS score of 9 (severe cognitive impairment) and for ADL care it stated, Helper does all of the effort. Resident does none of the effort to complete the activity. Record review of Resident #67's Care plan, dated 12/30/24, revealed Provide and serve diet as ordered. In an interview and observation on 05/05/25 at 8:15 AM, CNA M was observed feeding Resident #67 breakfast while she was standing over the resident as he was in bed. She stated they were required to be sitting down at eye level with the resident while feeding them. She stated the reason for doing so was a dignity concern. In an interview on 05/05/25 at 8:20 AM, RN T stated she was the hall nurse for Resident #67. She stated staff was required to be sitting at eye level while feeding residents. She stated the reason for doing so was to ensure the resident was not eating too quicky and you could observe if the resident was choking. She stated it was also a dignity concern. In an interview on 05/06/25 at 8:53 AM, the DON stated she had been at the facility more than 4 years. She stated she was made aware of staff feeding Resident #67 while standing over him. She stated she expected the staff to provide general care to the resident and ensure they got the nutrition and hydration they needed in a private setting. She stated policy stated staff should provide one on one interaction at eye level. She stated the risk of not following protocol when feeding residents could impact the engagement of the resident. Review of the facility's policy on Feeding the Resident, undated, revealed Staff member should position themselves so that the resident is at eye level with the staff member for better communication with the resident and to provide feeding in a dignified manner.

Based observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #1) of five residents reviewed for Pharmaceutical Services. The facility failed to ensure RN F disposed of Resident #1's Lorazepam (medication for anxiety) properly on 05/04/2025. This failure could place residents at risk of not receiving medications as ordered by the physician. Findings included: Record review of Resident #1's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with encephalopathy, respiratory failure, chronic kidney disease, and cerebrovascular disease. Record review of Resident #1's Quarterly MDS Assessment, dated 04/17/2025, reflected the resident had severe impairment in cognition with a BIMS score of 07 (resident required significant assistance and support in daily life). The Quarterly MDS Assessment indicated the resident was receiving hospice care. Record review of Resident #1's Comprehensive Care Plan, dated 04/18/2025, reflected the resident did not have a care plan for hospice care. Record review of Resident #1's Physician Order, dated 05/04/2025, reflected Lorazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet via G Tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) every 2 hours as needed for Anxiety for 14 Days. In an interview and observation on 05/04/2025 at 10:36 AM revealed RN F was receiving orders from Hospice Nurse M and one of them was to administer Lorazepam via g-tube. She said she would put the order in the system and then would give the medication because the Resident #1 was observed being restless. After transcribing the order, she placed one tablet of Lorazepam 0.5 mg in a small plastic cup but eventually the tablet fell on the floor. She said she would prepare another one and would dispose the one that fell . She placed another Lorazepam 0.5 mg tablet in a small plastic cup, crushed it, and returned it to the small plastic cup. She then prepared the water that she needed to flush the g-tube and to incorporate on the crushed medication. She went inside the room, took the resident's overbed table, sanitized it, placed the things she prepared for medication administration, and rolled it back beside the resident's bed. She sanitized her hands and the bell of the stethoscope, put on a gown and a pair of gloves, and pull the privacy curtain. The Lorazepam tablet was still on the floor and was now not within her sight because of the pulled privacy curtain. RN F proceeded to administer Resident #1 medication. After medication administration, she gathered the things used for medication administration and threw them in the trash can. She tied the plastic bag on the trash can, exited the room, and went to the utility room to throw the trash bag. The utility room was approximately five rooms away from Resident #1's room. The Lorazepam tablet was still on the floor when she went to the utility room. She went back to her cart and called ADON A to witness her dispose it and co-sign it. She picked up the tablet and put it in a pill tablet crusher. ADON A crushed it, threw it in the sharp container, and then co-signed the narcotic sheet for the resident's Lorazepam. In an interview on 05/04/2025 at 10:58 AM, RN F stated she dropped the Lorazepam on the floor when she was preparing the medication. She said she should had picked it up immediately and disposed it. She said she should have not left it on the floor because a resident might pick it up and consume it. She said the resident might be allergic to the medication, choke on it, or might have a bad stomach for consuming something from the floor. In an interview on 05/05/2025 at 12:19 PM, ADON A stated the staff should have picked it up when it fell on the floor and should not be left unattended because a resident might picked it up and ingest it. She said a resident might choke on it. She said RN F called her to assist her with the disposal but did not know that the medication was left unattended on the floor for a period of time. She said the expectation was to dispose any narcotics immediately and not leave it on the floor. She said she would coordinate with the DON to do an in-service regarding proper disposal of narcotics. In an interview on 05/05/2025 at 2:20 PM, the DON stated the Lorazepam is a narcotics and should not be left unattended on the floor. She said the staff should had picked-it up, dispose or secure it if she was in a hurry. She said the tablet should have been dispose at once and not left on the floor unattended because somebody might pick it up, swallow it, and choke. She said somebody might overdose as well. She said the narcotics were placed in a locked box inside the carts so nobody unauthorized could access them. She said the same principle applied in disposing of the narcotics. She said the expectation was for the staff to know that narcotics should be disposed immediately. She said she would educate the staff about proper and immediate disposal of narcotics. In an interview on 05/06/2025 at 8:52 AM, the Administrator stated narcotics should not be left unattended on the floor where residents could pick it up and swallow it. He said the resident might be allergic to it or might choke on it. He said the expectation was for staff to dispose of the narcotics immediately and not left unattended. He said he would coordinate with the DON to do an in-service about disposal of narcotics. Record review of the facility's policy, Medication - Wasting Controlled Substances undated, revealed Purpose: 1. To dispose of controlled substances that has been refused or contaminated during medication pass.

Based on observations, interviews, and record review, the facility failed to ensure the medication for one (Resident #5) of fifteen residents stored in locked compartments and only authorized personnel had access. The facility failed to ensure Resident 5's zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's left side table on 05/04/2024. This failure could place the residents at risk of not receiving medications, accidental overdose, or misuse of medications. Findings included: Record review of Resident #5's Face Sheet, dated 05/04/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with delusional disorder (brain disorder were an individual have delusional thoughts), depression (a mood disorder that cause a feeling of sadness and loss of interest), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Record review of Resident #5's Comprehensive MDS Assessment, dated 04/26/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 10 (resident may need additional support and monitoring). The Comprehensive MDS Assessment indicated the resident had Alzheimer's, depression, and psychotic disorder. The resident was also incontinent for both bladder and bowel. Record review of Resident #5's Comprehensive Care Plan, dated 05/04/2025, reflected the resident used antidepressant, hypnotic medication, had an impaired cognitive function, and required assistance for incontinent care. Record review of Resident #5's Progress Notes on 05/04/2025 did have any documentation that the resident wanted the barrier cream on top of her table. Observation on 05/04/2025 at 9:13 AM revealed Resident #5 was in her bed with eyes closed. A container of zinc oxide was observed on top of the resident's right side table. In an interview and observation on 05/04/2025 at 9:59 AM, CNA C stated she used zinc oxide after every incontinent care to prevent redness of the bottom. She said after she used it, she should not left on the side table because the resident might be confused and mistakenly swallow the cream. CNA C went inside Resident #5's room and put the zinc oxide inside the resident's drawer. She said the resident might ingest it and might be allergic to it. In an interview on 05/05/2025 at 12:19 PM, ADON A stated zinc oxide should be not within reach of a resident because the resident might ingest it. She said zinc oxide had chemicals that could be toxic when ingested by confused residents. she said the expectation was for the staff to put the zinc oxide where the resident could not reach it. She said she would coordinate with the DON about making sure there were no treatment cream within reach of the residents. In an interview on 05/05/2025 at 2:20 PM, the DON stated the zinc oxide, used during incontinent care, should be placed inside the drawer of the side tables after using it. She said if the resident or a visitor ingested it, there could be adverse reactions especially if somebody who accidentally ingested the medications were allergic to the medications. She said the expectation was the treatment cream used for incontinent care be placed inside the drawer to secure it. She said she would do an in-service making sure no treatment creams were accessible to the residents. In an interview on 05/05/2025 at 2:43 PM, Resident #5 said nobody told her that the zinc oxide should not be on top of the table. She said she would not mind if the barrier cream was placed inside her drawer. In an interview on 05/06/2025 at 8:52 AM, the Administrator stated the barrier cream should not be within reach of the residents because they might ingest it. He said if it was not for ingestion and was ingested, it might cause adverse reactions like allergy. He said he would coordinate with the DON to educate the staff about the matter. Record review of the facility policy, Storage of Drugs, Operational/Resident Care Policies, undated revealed, All drugs and biologicals are stored . Drug Security . All drugs used externally will be stored separately.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Residents #4,) of three residents reviewed for pharmacy services. 1. The facility failed to administer medications as ordered, Lidocaine HCL at 5% external patch to Resident #4 on 03/18/24, 03/19/24, 03/21/24, 03/24/24,and 03/26/24. These failures placed residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician. Findings included: Record Review of Resident #4's quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Parkinsonism, asthma, and chronic lower back pain. Resident #4 was moderately impaired for decision making and required one staff for assistance with activities of daily life. Record Review of Resident #4's Physician Orders reflected: 03/01/24 Lidocaine HCL at 5% external patch (pain and stiffness) apply to lower back one time a day. On in the am off in the pm as scheduled. 03/27/24 Lidocaine HCL at 4% OTC (over the counter)external patch apply to lower back one time a day. On in the am off in the pm as scheduled. Record Review of Resident #4s MARs for March 2024 reflected the Resident # 4 did not receive: Lidocaine HCL patch at 5% external patch on 03/18/24, 03/19/24, 03/21/24, 03/24/24, and 03/26/24 for the am dose. In an observation and interview on 03/26/24 at 11:21 a.m. with MA C revealed while administering Resident #4's medications, there were no Lidocaine patches available to apply to her back. MA C stated the Lidocaine patches had been ordered but had never come in. MA C stated she told the nurse in charge, and they order them, but she did not have any. In an interview with Resident #4 on 03/27/24 at 11:10 a.m. revealed the facility did not have any Lidocaine patches for her back yesterday and several days last week, and the week before. Resident #4 stated when she admitted to the facility, she was using the Lidocaine patches already and her doctor had told her it was alright to continue to use them. She stated this was the only month (March) that had been inconsistent, the other months had been fine, and she had received her patches without any problems. Resident #4 stated she had asked every day, but sometimes they have them and sometimes they do not, when I asked the lady that was supposed to put them on my back, she tells me the patches have been ordered but they have not come in. Resident #4 stated she had been okay without them so far, her back was stiff, but did not hurt, her back feels better when she has them, I still can do everything I usually do without any pain. In an interview on 03/27/24 at 2:00 p.m. with LVN B revealed if there was an over-the-counter medication that required re-ordering than I would tell the DON or the central supply personal. LVN B stated the Lidocaine patches are kept in the medication room on the shelf if you don't have any on the cart. If they are not there or on the cart, then I would look on the other carts to see if there are any. In an interview on 03/27/24 at 2:10 p.m. with LVN A revealed the over-the counter drugs are given by the medication aide and not the nurse. If the medication needed to be reordered the medication aide would tell me and I would reorder in the computer system. LVN A stated we have a lot of residents that are on Lidocaine patches, I am not aware of needing to reorder the lidocaine patches for anyone. In an interview on 03/27/24 at 2:20 p.m. with the DON and Administrator revealed the Lidocaine patches had been a problem. The DON stated the doctors wanted to order the Lidocaine patches 5% and our pharmacy formulary will not pay for those. The DON stated she was just made aware of this problem yesterday. The DON stated she had contacted the physician and their nurse practitioners to inform them that the Lidocaine patches 4% would be covered by the formulary on yesterday. I told the physicians that the new orders should read Lidocaine patches 4%. The DON stated she was not aware the Resident #4 had not been receiving her lidocaine patches as the physician ordered. An interview on 03/27/24 at 2:45 PM with the Medical Director revealed the physician was not aware of the facility having had an issue with getting medications from the pharmacy . The DON informed me yesterday that the Lidocaine patches that were ordered were not covered by the pharmacy and I had to order the lesser strength. (4 %) I was not informed that Resident #4 had only been receiving Lidocaine patches inconsistently this month. The facility was good about communicating with me, but I did not know about the failure to provide medication that had been ordered. Review of the Facility undated Policy and Procedure, Medications, Ordering and Receiving from Pharmacy reflected: Purpose: 1. To ensure timely arrival of medications ordered from the pharmacy .procedure: 1. Medications orders are phoned or faxed to the pharmacy and written on a medication order form provided by the pharmacy for the purpose. The entry includes: a. dated ordered. b. Whether the order is new or a repeat order (refill), if the repeat order, include prescription number. c. patients name and room number d. medications name and strength, when indicated. e. Direction for use, if a need order or direction change to previous order g. Physician's name 2. Info ration concerning repeat medications (refills) will be written on a medication order form provided by the pharmacy for that purpose, or transferred to the form on a peel-off label, and ordered as follows: a. Order medication within 72 hours of the last dose available. B. the nurse who orders the medication is responsible for notifying the pharmacy of changes in directions for use of previous labeling errors. C. The refill order is called in, faxed, or otherwise transmitted to the pharmacy . Receiving Medications: 1. A licensed nurse receives medications, delivered to the facility and documents delivery on the medication receipt record. Theis nurse verifies medications received and directions for use with the medication order and receipt record. Discrepancies and omissions are reported promptly to the issuing pharmacy and the charge nurse supervisor. 2. Pharmacy delivers medications with that delivery receipt or check-off and documentation by the nursing staff. A report of all medications delivered is provided with the scheduled delivery. 3. There delivery records are retained for an appropriate amount of time to reconcile and reordering issues.

Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, including acute charting guidelines and post fall procedures necessary to care for resident's needs as identified through resident assessments and nursing documentation, for 1 (Resident #1) of 4 residents reviewed for quality of care. 1. LVN A failed to communicate, use the acute charting guidelines, and post fall procedures, to the oncoming charge nurse at the change of shift, leaving RN B unaware Resident #1's required follow-up assessment, due to a previous fall. These failures placed residents with falls at risk for complications to include discomfort/injury and for residents not to receive needed nursing assessments. Findings included: Review of Resident #1's MDS electronic admission form dated 12/25/23 revealed the resident was a [AGE] year-old female admitted on [DATE] and discharged on [DATE]. Diagnoses to included: Nontraumatic subarachnoid hemorrhage (bleeding in the tissue of brain), cerebral aneurysm (bleeding in the brain), multiple intracranial hemorrhages (bleeding in the brain), heart failure (heart not pumping correctly), Hypertension (increased blood pressure), Diabetes (increased sugar), malnutrition ( poor nutrition), respiratory failure (unable to breath without assistance), and sickle cell (disease of the blood). Resident #1 had a BIMs of zero (severely cognitively impaired) and required extensive assistant for activities of daily living. Review of Resident #1's care plan dated 12/24/23 revealed problems addressed included the resident's needs for functional status, high risk for falls, interventions in place for falls, feeding tube and risk for infections. The care plan reflected Resident #1 required assistance of two for ADLs to include bed mobility. Goals included the resident's high risk for falls, the feeding tube would remain patent, she would receive adequate nutrition without side effects associated with tube feedings. Interventions included for falls: low bed, air loss mattress with bolsters on bed, and stability mats on floor. Review of the 24-hour reports dated 12/22/23 through 12/25/23, reflected on 12/22/23 Resident #1 had an unwitnessed fall from her low bed with no injuries noted and , on 12/23/23 Resident #1 was still monitored for the fall from the bed. On ,12/24/23 Resident #1's fall had dropped off the 24-hour report and on 12/25/23, there was no documentation of the fall. Review of the progress notes dated 12/22/23 through 12/25/23, reflected Resident #1 had an unwitnessed fall from her low bed. The assessment of the resident was documented along with the notification of the physician and the responsible party. There were already interventions in place, the therapy department was treating the resident at the time and rescreened the resident at the time of the fall. In an interview on 12/30/23 at 9:30 a.m. with RN A revealed that she had cared for Resident #1 and was the nurse in charge on 12/25/23 but was not present when she had gone to the hospital . RN A stated resident #1 went to the hospital on 12/26/23 with a fractured left leg. RN A stated she had seen Resident #1 three times on 12/25/23 but had not assessed her lower legs for any injuries to her legs, because she had no idea that she had a fall previously, she had not been told the information during change of shift. RN A stated it must not have been on the 24-hour report. RN A stated that if a resident fell , we they were to assess them, call the doctor, call the reasonable party;, and if the resident has no apparent injures, we they were to continue to monitor them for the next 72 hours for any injuries that could arise after the fall,. She stated they were we are to document on the 24-hour report and tell each other between shifts. In an interview on 12/30/23 at 10:15 a.m. with ADON C revealed he had been working the day that Resident #1 was found on the floor on the mat next to her bed. ADON C said the resident was a wiggler in the bed so they had placed put a lot of interventions in place. ADON C said that the CNA had come came to get him, he assessed the resident, there were no injuries, she had full range of motion with no pain, and no skin abrasion or tears, He stated he helped place her back in bed, from there the charge nurse LVN A was told and she would follow the fall protocol. ADON C said the protocol was to call the physician and the responsible party and then fill out the forms for incident /accident and then the nurses were to monitor the resident for the next 72 hours to check for any latent injuries related to the incident/accident. ADON C stated the information should be placed on the 24-hour report to be passed on to the next shift, as part of the shift change communication. ADON C stated that on 12/25/23 around 6:30 p.m. he was working at the facility as a medication nurse and the family came and ask him to look at her Resident #1's left leg. He stated he did go and look the left leg it was swollen and painful. He stated he went and got the charge nurse (RN E) and she assessed called the physician and followed through . In an interview on 12/30/23 at 11:00 a.m. revealed the Medical Director stated he was aware of Resident #1's fall. He stated that the nursing staff was good about communicating with him about changes in residents' conditions. He stated the LVN A had contacted him on 12/24/235 about the cool left leg and the resident complaining of pain, so he had ordered doppler studies, then he was contacted about the swelling of the leg and pain on 12/25/23. He stated he, ordered x-rays and then he was contacted with the results of the fracture , and she was sent out. The physician stated during the interview that it would not be unusual for the resident to have a partial fracture that did not exhibit pain and then continue with therapy and care until the partial fracture became a full fracture and swelling with exhibited pain. The physician stated Resident #1 was very compromised and fragile. The physician stated he had reviewed the admission paperwork to the hospital and discussed with the investigator, reflecting that the surgeon at the hospital did not identify the fracture to be old, as acute at the time of the admission to the hospital, the surgeon stated he could not perform the surgery the same day, due to her sickle cell condition and the need for blood. The surgery was completed on the 12/27/23. The resident was transferred to another skilled nursing facility two days later. Review of the x-ray's of the bilateral hips and the left femur dated 12/25/23 reflected: femur (thigh bone) left leg reflecting an obliquely posteromedial displaced fracture femoral diaphysis (a fracture that requires surgery to realign the bone). Review of the progress notes dated 12/20/23 through 12/25/23 for all three disciplines physical therapy, occupational therapy, and speech therapy, reflected Resident #1 had been treated on 12/20/2, 12/21/23, 12/22,23, and 12/25/23. There documentation reflected no complaints of pain or swelling with Resident #1. In an interview on 12/30/23 at 2:45 p.m. with LVN A revealed she had been the nurse in charge for Resident #1 on 12/22/23, 12/23/23, and 12/24/23. LVN A stated she was working when Resident #1 was found on the floor mat on the right side of the bed. She assessed following the ADON C's assessment and she did not find any injuries or complaints of pain at that time. She filled out the required reports, called the physician, and informed the responsible party and documented on the 24-hour report about her fall. LVN A stated on 12/24/23, the family came to visit . LVN A stated the family told her that the left leg was tight. LVN A stated the leg was not tight (another description of swelling) and no pain affect was noted by the resident when she assessed Resident #1, until the family asked the resident about pain and she responded yes. LVN A stated since the resident expressed pain to the family and the leg was cold to the touch, she called the physician, and he ordered a doppler study arterial and venous (testing for circulation to determine if the person has a blood clot). She called the company and ordered the study and wrote it on the 24- hour report and reported it to the oncoming nurse, LVN E and she left. LVN A stated that was what we they were supposed to do with any change of condition with the resident, anything new, they document and place it on the 24-hour report, so the incoming nurse can could be told., she did not recall if she documented about the follow-up for the fall on the 24-hour report, or discussed the follow-up on the fall at change of shift on 12/22/23, but knew she was supposed to. Attempts were made on 12/30/23 to contact LVN D, with messages left with no return call by the time of exit. Review of the progress notes dated 12/22/23 reflected LVN A had documented the fall, the assessment, the notification of the physician and the notification of the responsible part, and the nursing administration. Further review of the nursing progress notes reflected LVN had documented the follow-up assessment of Resident #1. On 12/24/23 LVN A had documented the assessment of Resident #1 with her change of condition related to the left leg, calling the physician and ordering the doppler studies (circulation studies to rule out blood clots) for the left leg. In an interview on 12/30/23 at 5:13 p.m. with RN D revealed that she was the charge nurse on 12/25/23 for the next 16 hours. RN D stated she had just completed making her general rounds right after coming to work and had seen Resident #1 then, when ADON C came and told her that Resident # 1's leg was swollen and painful. RN D assessed the resident, called the doctor and got x-rays ordered and an order for Tramadol (pain medication) to be given one time. RN D stated the left leg was swollen and the resident exhibited pain while she assessed her. The results of the x-ray were positive for a fracture of the femur (thigh bone) left leg reflecting: an obliquely posteromedial displaced fracture femoral diaphysis (a fracture that requires surgery to realign the bone). The physician was made aware of the results, and he wanted her transferred to the emergency room . RN D stated that she followed those orders and sent her out. RN D stated this that was the first time she had seen this resident, since she had been off, and she had not but she had not been told by the off going nurse, RN B that the resident had a fall. Interview on 01/03/24 at 11:00 a.m. with the DON she stated the nursing staff was required to assess for any changes in the resident and then contact the physician. All information concerning falls, labs, tests, new medications, should be written on the 24-hour report and that was something all nurses had been told. The nursing staff needed to have that information, so they could communicate between shifts so each nurse would know what was occurring with the resident. The DON stated concerning Resident #1 the process did not happen so the oncoming nurse had no idea the resident had a previous fall, and she did not know to assess her. The DON stated on the ins-service she had just recently given, she had made it clear to the nursing staff if they did not report on the 24-hour report or perform the fall follow-up, it could result in disciplinary action, possible termination. She was tired of some of the nurses not listening to her. In an interview on 01/03/24 at 11:25 a.m. with the Director of Therapy revealed she knew Resident # 1 and the resident was in their services from the time of evaluation on 12/202/3 until she discharged on [DATE]. The Director of Therapy said that the resident was receiving all three disciplines when she fell out of her low bed. There was not any indication that she had pain or no swelling noted to her lower extremities, occasionally her confusion was worse than usually so we would try her therapy the next day, when she could not cooperate due to her confusion. The Director of Therapy stated the therapy department was aware she had fallen out of her low bed, and we did complete an additional fall screen, even though she was in our services at the time. There were no further actions to be completed or added at that time. Review of the in-service dated 01/02/24 reflected all nursing staff for acute charting guidelines and post fall procedures was given by the DON. Review of the undated policy and procedure Acute Charting Guidelines reflected: Acute charting must include . the families to be notified of change in resident status 10. D. all unobserved . whether or not it as a tear, bruise, or a fall, must be charted on for 72 hours . notify the family and doctor After the fall . E. the nurse will observe for delayed complications of a fall for seventy- two (72) hours after a fall Review of the undated policy and procedure Nursing Services reflected the facility will sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services, to assure resident safety and attain or maintain the resident practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments .the facility will ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, and identified through resident assessments .providing care incudes but not limited to assessing

Based on observations, interviews and record reviews, the facility failed to treat each resident with a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for one of ten residents (Resident #1) for resident rights. The facility staff failed to send Resident #1 to the hospital or emergency room when Resident #1 had requested at 8:47 AM, 8:49 AM and 8:59 AM on [DATE]. After one hour, Resident #1 was found unresponsive and coded at the facility on [DATE]. This failure resulted in an Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This deficient practice could place residents at risk of not receiving treatment and possible death. Findings include: Record review of Resident #1's face sheet dated [DATE] reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] reflected Resident #1 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had a BIMS (Brief Interview Mental Status) score of 8 which indicated he had moderate cognitive impairment based on ,d+[DATE] score. The MDS assessment indicated Resident #1 had clear speech and usually understood self and others. The assessment reflected Resident #1 had no behavior displaced and the resident was required to have extensive assistance with one to two people for his Activity of Daily Livings. The resident had no impairment for his upper and lower extremities. Resident #1 used wheelchair for his mobility, and he was frequently incontinent for his bowel and bladder. Record review of Resident #1's care plan, date initiated [DATE], reflected, Resident request to be full code status. The intervention included communicate resident choice, informed physician and family of any changes to condition, and respect residents end of life decision. Record review of Resident #1's vital sign record dated [DATE] reflected Resident #1 had pulse of 66 bpm, 17 breaths per minute, 97.4-degree F (forehead, non-contact) and blood pressure of ,d+[DATE] mmHg documented at 9:15 AM on [DATE], oxygen saturation of 93% at room air documented at 10:59 AM on [DATE]. Record review of the video clips reflected Resident #1 told CNA A and ST B that help, help at 8:47 AM and he wanted to go to the emergency room at 8:49 AM on [DATE]. Then, LVN C entered the resident room and obtained the vital sign. During assessment, LVN C asked him whether he wanted to go to the hospital or doctor appointment for that day ([DATE]), Resident #1 answered he wanted to go to the hospital at 8:54 AM. The record indicated there was no follow up question by LVNC to Resident #1 for requesting sending him out to the hospital during assessment. An interview on [DATE] at 11:04 AM, CNA A revealed she worked at the facility for two years. CNA A stated she was assigned to take care of Resident #1 on [DATE] on the morning shift. CNA A stated Resident #1 was fine before breakfast, but he did not eat his breakfast and he looked clammy. CNA A stated Resident #1 reported he did not feel that good and said something like wanting to go to the hospital. CNA A stated she could not recall exact time on the morning of [DATE] and she was with ST B when checking Resident #1. CNA A stated she reported to LVN C and saw that LVN C grabbed the vital sign machine and entered Resident #1's room. CNA A stated LVN C told her that Resident #1's vital sign was within normal range. After checking other residents at an unknown time, CNA A stated she saw the nurses were doing CPR on Resident #1. An interview on [DATE] at 11:00 AM, Resident #1's family member revealed the family member did not receive notification from LVN C regarding about Resident #1 had requested to go to the hospital on the morning of [DATE]. The family member stated they received a phone call from the facility staff regarding about the resident was found unresponsive and providing CPR on [DATE]. The family member stated they found out Resident #1 had requested sending him out to the emergency or hospital after they had received the video clips. The family member stated Resident #1 had no history of requesting of sending him out during his stay at the facility. An interview on [DATE] at 11:04 AM on [DATE], CNA A stated Resident #1 was more like pale, sweating, looked more disoriented and she reported that information to LVN C on [DATE]t unknown time. CNA A stated she did not report Resident #1's request wanting to go to the emergency roiagnom on [DATE]. Record review of Speech Therapy's Treatment Encounter Note (s) for Resident #1, dated [DATE] and signed by ST B, reflected, pt [Patient] seen at bedside for tx [treatment], with AM [morning] meal tray. Pt lethargic on this date, but initially alert and attentive to task and meal, answering all questions presented appropriately. mech [mechanical] soft trial completed for meal tray but pt with prolonged perseverative mastication d/t [due to] fatigue. Solids not deemed appropriate during AM meal d/t fatigue and poor meal endurance. Total feed assist provided for small bites of oatmeal and small cup sips of thin liquids. Pt noted with wet vocal quality of intermittent cough. Pt skin cold and face appearing somewhat pale. Pt recommended to not consume breakfast d/t declining . CNA in room, educated to hold tray d/t poor tolerance and lethargy, pt unable to tolerate breakfast safely on this date. CNA verbalized understanding ad agreement. Pt then voice, I want to go to the emergency room . Charge nurse . educated on pat status, inability to tolerate food/liquids, pt's decline from previous tx, and pt request to be sent to hospital. Care handed off to nurse to intervene on pt's needs. A telephone interview on [DATE] at 2:03 PM, ST B was revealed she worked at the facility for three years as speech therapy. ST B stated Resident #1 reported that he wanted to go to the emergency on [DATE] but ST B was unable to recall an exact time on that morning ([DATE]). ST B stated Resident #1 appeared to be unable to participate on the speech therapy, Resident #1 stated the resident wanted to go to the hospital. ST B stated she reported to the c [NAME] nurse [unable able to recall who was the charge nurse] and the charge nurse told ST B that she would check him out. ST B stated she went to check other residents after she reported to the charge nurse. ST B stated she heard Resident #1 was coded on that morning. An interview on [DATE] at t 9:51 AM, LVN C stated she went to check and assessed Resident #1 on [DATE] [unable to recall exact time] after she received report from CNA A and ST B that Resident #1 was not himself. LVN C stated she did not receive from CNA A or ST B that Resident #1 wanted to go to the emergency room . LVN C stated she obtained Resident #1's vital sign which were within normal range and Resident #1 answered her questions. LVN C was aware that Resident #1 had medical appointment on [DATE]. When LVN C asked Resident #1 whether he wanted to go to the hospital or to his medical appointment, LVN C stated Resident #1 replied he wanted to go to the hospital. Then, LVN C stated she would call his family member and Resident #1 agreed. LVN C stated the family members had requested to call them first before sending him out to the hospital. However, LVN C stated she did not call Resident #1's immediately or notify the physician . LVN C stated she continued to do her morning round to other residents. LVN C stated she normally completed her morning round and sat down at the nurses' station and started to process transferring or discharging. Before she could sit down and called Resident #1's family member, Resident #1 had coded, and it was a shock to her. LVN C stated she could not recall how long it took to complete her morning round depending on the residents' condition daily. LVN C stated she did not ask for help on that morning to anyone transferring or discharging of Resident #1 on [DATE]. LVN C stated she had documented Resident #1's vital sign on the medical record and she could not recall what his vitals were. LVN C stated Resident #1 was transferred to the hospital after the paramedics revived him on [DATE] . LVN C stated the residents would have many complications including death when they did not receive medical treatment without delay. Record review of Resident #1's Fire Department report dated [DATE] reflected a 911 was called for Resident #1 at 10:11 AM on [DATE]. The report indicated that Resident #1 was revived at 10:42 AM on [DATE] and then he was transferred to the hospital. Record review of nurses' notes for Resident #1, dated [DATE] at 10:01 AM and signed by LVN C reflected, While visiting with roommate nurse notices resident in bed unresponsive no pulse detected said nurse initiates CPR with chest compressions. 911 called. Family notified. Blood glucose levels checked @ 120mg/dl, CPR continued until EMS arrives and takes over. Pulsed detected @71 patient taken to [hospital] accompanied by wife. Record review of Resident #1's hospital record dated [DATE] reflected Resident #1 expired at the hospital at 1:38 PM on [DATE]. The hospital record reflected Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan, 24 hours nurses' notes, and nurses' notes reflected there was no information indicated that Resident #1's family member had requested to call them first before sending him out to the hospital when the resident had requested it. An interview on [DATE] at 2:04 PM, the DON revealed ADON E found Resident #1 unresponsive on the morning of [DATE] and initialed CPR (Cardiopulmonary resuscitation (CPR) is an emergency procedure that can help save a person's life if their breathing or heart stops immediately). Then, Resident #1 was transferred to the hospital after paramedic (an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system) revived him. An interview on [DATE] at 12:10 PM, the DON stated she expected all the nurses to assess the residents first when reporting of change of condition or request to go to the emergency or hospital as soon as possible. The DON stated she was not aware of Resident #1's family member had requested to call them first when Resident #1 wanted to go to the hospital until today ([DATE]) from LVN C after inquiry. The DON expected for the staff to call the physician immediately to get more medical attention depending on the resident's significant condition to transfer. An interview on [DATE] at 2:11 PM, ADON E stated she found Resident #1 was unresponsive while checking on him during providing care to Resident #2 who was roommate of Resident #1 on [DATE]. ADON E stated she did not recall exact time that she found Resident #1 unresponsive and called for a code response. ADON E stated she checked Resident #1's pulse, but no pulse was identified. She stated she and the other nurses initiated CPR immediately. ADON E stated Resident #1's body was still warm. ADON E stated the nurses stopped compression and handed that over to paramedic team after they arrived at the resident room. ADON E stated the paramedic team had worked on him for about 30 minutes, then they got response of Resident #1's pulse, then Resident #1 was transferred to the hospital. ADON E stated she talked with the resident's family member later on that day ([DATE]) and was notified Resident #1 expired at the hospital around 2 PM on [DATE]. ADON E stated she had no knowledge about Resident #1 had requested to go to the hospital or emergency room prior to calling a code. ADON E stated she expected all nurses to start transferring or discharge to the hospital or emergency room when the resident requested without delay. At 11:24 AM on [DATE], ADON E stated she heard that LVN C said she needed to call Resident #1's family first before sending him out to the hospital on [DATE]. However, she was not aware of LVN C called Resident #1's family or not prior to response him CPR on [DATE]. ADON E stated the resident would have delay in receiving medical treatment when the resident requested to go to the hospital and the nurses did not do the transfer or discharge process immediately. An interview on [DATE] at 3:11 PM on [DATE], LVN D revealed she worked at the facility for two weeks as a wound care nurse. LVN D stated she worked at the facility on [DATE] and she stated Resident #1 coded while she was providing care for Resident #2 who was Resident #1's roommate. LVN D stated she did not recall exact time that Resident #1 was coded. LVN D stated she left the room after the paramedic team arrived in the resident's room on [DATE]. An interview on [DATE] at 3:29 PM on [DATE], the Administrator revealed he was aware of Resident #1 was coded on [DATE] and the nurses were working with him until paramedics arrived. The Administrator stated he knew that Resident #1 was transferred to the hospital after coding him, however, he did not know Resident #1 had requested going to the hospital or emergency room prior to coding him. The administrator stated the resident would not receive a proper medical treatment when they requested to go to the hospital and they were not sent out immediately or delay on sending them. An interview on [DATE] at 12:54 PM, the MD G stated she had received text message when Resident #1 was coded on [DATE]. The MD G stated she did not receive report about Resident #1's request for emergency or hospital transfer. The MD G stated the resident would be transferred to the emergency or hospital when the resident or their family member requested sending to the hospital even though the resident had stable condition. An interview on [DATE] at 11:50 AM on [DATE], LVN F stated he worked at the facility for six months. LVN F stated he normally assigned to take care of Resident #1; however, he did not work on [DATE] the day Resident #1 was coded. LVN F stated he was not aware he had to call his family first when Resident #1 had requested to go to the hospital. LVN F stated he would not wait to transfer or discharge the resident when they requested to go to the emergency or hospital. If needed, he would call the family member first and sent them out without delay. LVN F stated he was aware of resident rights to be honored when requesting going to the emergency or hospital. Record review of the facility's policy on Transfer/Discharge of a Patient reflected, Purpose: To transfer and/or discharge a patient from the facility with the least amount of trauma and maximum amount of care and dignity. Procedure: 1. Notify attending Physician, family, or responsible party. Record review of the facility's policy on Transfer and Discharge reflected, Transfer and discharge requirements: The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 6. The resident or resident representative requests a voluntary transfer or discharge. Notice Before Transfer or Discharge: Before a resident is transferred or discharged , the facility will notify the resident and the resident representative about the transfer or discharge. This notice shall be in a language and manner they understand. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:14 PM. The IJ template was provided to the Administrator on [DATE] at 4:14 PM. The Plan of Removal was accepted on [DATE] at 4:26 PM and revealed: Purpose: The purpose of this action plan is to take steps to remove the immediate jeopardy in failing to ensure a resident was sent to the emergency room when Resident # 1 requested several times on [DATE]. On [DATE], Resident # 1 reported to a Speech Therapist # 13 [ST B] and a C.N.A. # 12 [CNA A] that he was not feeling well and requested to be sent to ER. LVN Charge Nurse # 6 [LVN C], assessed resident, obtained full set of V/S to include blood sugar, noted resident to be in stable condition. LVN Charge Nurse # 6 [LVN C] questioned resident if he would like to go to scheduled physician appointment or to be sent to hospital, resident responded to go to hospital. Per family request, LVN Charge Nurse # 6 [LVN C] informed resident that she would call family to notify them of request to be sent out to hospital, resident responded stating okay. Resident coded prior to being sent out. Action Plan incorporated to ensure systems are in place to ensure correction and removal of the Immediate Jeopardy: 1. RN DON # 1 [DON], RN # 2 [RN Z] , LVN # 3 [ADON S], LVN # 4 [ADON E], LVN # 5 [LVN Z] , LVN # 6 [LVN C], LVN # 7 [LVN F], LVN # 8 [LVN AA] and LVN # 9 [LVN BB] on [DATE] at 4:50 p.m [PM]. immediately assessed all current residents in the facility for any condition changes or any immediate medical issues that would warrant emergency transfer to the hospital to include asking the resident if they request a transfer to a hospital. These assessments will include a thorough head to toe assessment to include vital signs; blood pressure, temperature, respiration, oxygen sats, pain, neurological, cardiovascular, respiratory, GI/elimination, musculoskeletal, skin, & psychosocial. Any immediate assessments that are being done by the facility nurses that appear to indicate a change in a resident's condition or a medical emergency, the attending physician and the family will be notified by the RN DON # 1 [DON] for further orders and disposition. These head-to-toe assessments were completed on [DATE]. Results of all head-to-toe assessments and observations indicated no signs of any changes in conditions or the need for emergency medical assistance that would warrant a transfer to a hospital. 2. RN DON # 1 [DON] conducted an in-service training on [DATE] all licensed nurses, CMAs, and CNAs on identifying and reporting resident changes in condition and reporting to the physician any changes in condition. Staff not present for the [DATE] in-service training will be in-service trained on [DATE] and completed before that staff individual is allowed to start their work shift. All newly hired nursing personnel will be trained at their Orientation to the facility on resident changes of conditions and reporting these changes to their charge nurses where further reporting will be to the resident's attending physician for appropriate disposition to include any transfers to the local hospital. Examples of changes in condition were presented in the training sessions along with verbal interaction to confirm the understanding, importance and competency of the training. The following training was competed for all facility licensed nurse and a Post Evaluation test was administered to verify competency: Detecting Changes in a Resident's Condition; Know the Resident's Normal (Baseline) Condition; Recognizing Change: Top 12 Changes in Residents; and Responsibility for Observation & Reporting. 3. If a resident request to go to the hospital the facility will contact the attending physician and family and send the resident directly to the hospital as requested. Action plan to be incorporated to ensure systems are in place to monitor corrections. The administrator and the RN DON # 1 [DON], starting [DATE] and going forward, will review all 24-hour reports at the facility's daily stand-up meetings, which are current daily on-going meetings, to ensure that any and all changes of conditions were addressed and resolved. The administrator and the RN DON #1 will review and sign off on the reports to confirm that they were reviewed and acted upon if necessary. The Corporate RN # 10 [RN CC] starting, [DATE] will do monitoring with reviews of the 24-hour reports to ensure that all issues with resident changes in conditions are being documented and addressed. Included in these reviews the Corporate RN # 10 [RN CC] will randomly interview clinical staff on the items covered in the in-service training that was concluded on [DATE] and [DATE] to ensure that staff continue to be aware of changes in resident conditions and what the communication procedures are in documenting and reporting. These 24-hour reports will be scanned to the Corporate RN # 10 [RN CC] daily who will review each report and e-mail back to the facility administrator and the RN DON # 1 [DON] with comments or further action to be done. The RN DON #1 [DON] and the facility QAPI committee met and performed a Performance Improvement Plan (PIP) the Root Cause Analysis (RCA) of the deficient practice cited on [DATE]. The facility QAPI Committee will review and monitor weekly for the next month to ensure that the intervention plan is working as designed. The facility Medical Director # 11[MD G] was notified on [DATE] of the SQC/IJ and received a copy of this action plan on [DATE]. Administration and management are confident that the immediate jeopardy to any residents at [the facility] has been removed and addressed as of [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews were conducted on [DATE] with facility staff on all three shifts (LVN D, LVN H, LVN I, LVN J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA Q, CNA R, ADON S, LVN T, LVN U, CNA V, DM W, HS X, DOR Y, DON, and Administrator). The facility had a total of two different shifts [6 AM to 6 PM and 6 PM to 6 AM] for the nurses and had a total of three different shifts [6 AM to 2 PM, 2 PM to 10 PM, and 10 PM to 6 AM] for the other departments. Staff interviewed confirmed they received in-service training and were able to demonstrate how to identify the resident's change of condition and how to follow the facility protocol on emergency transfer when the resident had requested to go to emergency. Observations on [DATE] from 4:26 PM to 6:00 PM revealed no resident had been identified as having a change of condition and no delay on transferring or sending to the hospital identified. Interview with six alert residents [Residents, #2, #3, #4, #5, #6, and #7] on [DATE] from 5:00 PM to 5:30 PM revealed they did not have any issue to get a proper care including when they wanted to go to the hospital or emergency. An Immediate Jeopardy (IJ) was identified on [DATE]. The facility was provided with the IJ template on [DATE]. The administrator was informed the IJ was removed on [DATE] at 6 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's was still need to complete in-service training and evaluate monitoring the effectiveness of their corrective systems.

Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of ten residents (Resident #1) reviewed for quality of care. The facility staff failed to send Resident #1 to the hospital or emergency room when Resident #1 had requested at 8:47 AM, 8:49 AM and 8:59 AM on [DATE]. After one hour, Resident #1 was found unresponsive and coded at the facility on [DATE]. This failure resulted in an Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This deficient practice could place residents at risk of not receiving treatment and possible death. Findings include: Record review of Resident #1's face sheet dated [DATE] reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] reflected Resident #1 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had a BIMS (Brief Interview Mental Status) score of 8 which indicated he had moderate cognitive impairment based on ,d+[DATE] score. The MDS assessment indicated Resident #1 had clear speech and usually understood self and others. The assessment reflected Resident #1 had no behavior displaced and the resident was required to have extensive assistance with one to two people for his Activity of Daily Livings. The resident had no impairment for his upper and lower extremities. Resident #1 used wheelchair for his mobility, and he was frequently incontinent for his bowel and bladder. Record review of Resident #1's care plan, date initiated [DATE], reflected, Resident request to be full code status. The intervention included communicate resident choice, informed physician and family of any changes to condition, and respect residents end of life decision. Record review of Resident #1's vital sign record dated [DATE] reflected Resident #1 had pulse of 66 bpm, 17 breaths per minute, 97.4-degree F (forehead, non-contact) and blood pressure of ,d+[DATE] mmHg documented at 9:15 AM on [DATE], oxygen saturation of 93% at room air documented at 10:59 AM on [DATE]. Record review of the video clips reflected Resident #1 told CNA A and ST B that help, help at 8:47 AM and he wanted to go to the emergency room at 8:49 AM on [DATE]. Then, LVN C entered the resident room and obtained the vital sign. During assessment, LVN C asked him whether he wanted to go to the hospital or doctor appointment for that day ([DATE]), Resident #1 answered he wanted to go to the hospital at 8:54 AM. The record indicated there was no follow up question by LVNC to Resident #1 for requesting sending him out to the hospital during assessment. An interview on [DATE] at 11:04 AM, CNA A revealed she worked at the facility for two years. CNA A stated she was assigned to take care of Resident #1 on [DATE] on the morning shift. CNA A stated Resident #1 was fine before breakfast, but he did not eat his breakfast and he looked clammy. CNA A stated Resident #1 reported he did not feel that good and said something like wanting to go to the hospital. CNA A stated she could not recall exact time on the morning of [DATE] and she was with ST B when checking Resident #1. CNA A stated she reported to LVN C and saw that LVN C grabbed the vital sign machine and entered Resident #1's room. CNA A stated LVN C told her that Resident #1's vital sign was within normal range. After checking other residents at an unknown time, CNA A stated she saw the nurses were doing CPR on Resident #1. An interview on [DATE] at 11:00 AM, Resident #1's family member revealed the family member did not receive notification from LVN C regarding about Resident #1 had requested to go to the hospital on the morning of [DATE]. The family member stated they received a phone call from the facility staff regarding about the resident was found unresponsive and providing CPR on [DATE]. The family member stated they found out Resident #1 had requested sending him out to the emergency or hospital after they had received the video clips. The family member stated Resident #1 had no history of requesting of sending him out during his stay at the facility. An interview on [DATE] at 11:04 AM on [DATE], CNA A stated Resident #1 was more like pale, sweating, looked more disoriented and she reported that information to LVN C on [DATE]t unknown time. CNA A stated she did not report Resident #1's request wanting to go to the emergency roiagnom on [DATE]. Record review of Speech Therapy's Treatment Encounter Note (s) for Resident #1, dated [DATE] and signed by ST B, reflected, pt [Patient] seen at bedside for tx [treatment], with AM [morning] meal tray. Pt lethargic on this date, but initially alert and attentive to task and meal, answering all questions presented appropriately. mech [mechanical] soft trial completed for meal tray but pt with prolonged perseverative mastication d/t [due to] fatigue. Solids not deemed appropriate during AM meal d/t fatigue and poor meal endurance. Total feed assist provided for small bites of oatmeal and small cup sips of thin liquids. Pt noted with wet vocal quality of intermittent cough. Pt skin cold and face appearing somewhat pale. Pt recommended to not consume breakfast d/t declining . CNA in room, educated to hold tray d/t poor tolerance and lethargy, pt unable to tolerate breakfast safely on this date. CNA verbalized understanding ad agreement. Pt then voice, I want to go to the emergency room . Charge nurse . educated on pat status, inability to tolerate food/liquids, pt's decline from previous tx, and pt request to be sent to hospital. Care handed off to nurse to intervene on pt's needs. A telephone interview on [DATE] at 2:03 PM, ST B was revealed she worked at the facility for three years as speech therapy. ST B stated Resident #1 reported that he wanted to go to the emergency on [DATE] but ST B was unable to recall an exact time on that morning ([DATE]). ST B stated Resident #1 appeared to be unable to participate on the speech therapy, Resident #1 stated the resident wanted to go to the hospital. ST B stated she reported to the c [NAME] nurse [unable able to recall who was the charge nurse] and the charge nurse told ST B that she would check him out. ST B stated she went to check other residents after she reported to the charge nurse. ST B stated she heard Resident #1 was coded on that morning. An interview on [DATE] at t 9:51 AM, LVN C stated she went to check and assessed Resident #1 on [DATE] [unable to recall exact time] after she received report from CNA A and ST B that Resident #1 was not himself. LVN C stated she did not receive from CNA A or ST B that Resident #1 wanted to go to the emergency room . LVN C stated she obtained Resident #1's vital sign which were within normal range and Resident #1 answered her questions. LVN C was aware that Resident #1 had medical appointment on [DATE]. When LVN C asked Resident #1 whether he wanted to go to the hospital or to his medical appointment, LVN C stated Resident #1 replied he wanted to go to the hospital. Then, LVN C stated she would call his family member and Resident #1 agreed. LVN C stated the family members had requested to call them first before sending him out to the hospital. However, LVN C stated she did not call Resident #1's immediately or notify the physician . LVN C stated she continued to do her morning round to other residents. LVN C stated she normally completed her morning round and sat down at the nurses' station and started to process transferring or discharging. Before she could sit down and called Resident #1's family member, Resident #1 had coded, and it was a shock to her. LVN C stated she could not recall how long it took to complete her morning round depending on the residents' condition daily. LVN C stated she did not ask for help on that morning to anyone transferring or discharging of Resident #1 on [DATE]. LVN C stated she had documented Resident #1's vital sign on the medical record and she could not recall what his vitals were. LVN C stated Resident #1 was transferred to the hospital after the paramedics revived him on [DATE] . LVN C stated the residents would have many complications including death when they did not receive medical treatment without delay. Record review of Resident #1's Fire Department report dated [DATE] reflected a 911 was called for Resident #1 at 10:11 AM on [DATE]. The report indicated that Resident #1 was revived at 10:42 AM on [DATE] and then he was transferred to the hospital. Record review of nurses' notes for Resident #1, dated [DATE] at 10:01 AM and signed by LVN C reflected, While visiting with roommate nurse notices resident in bed unresponsive no pulse detected said nurse initiates CPR with chest compressions. 911 called. Family notified. Blood glucose levels checked @ 120mg/dl, CPR continued until EMS arrives and takes over. Pulsed detected @71 patient taken to [hospital] accompanied by wife. Record review of Resident #1's hospital record dated [DATE] reflected Resident #1 expired at the hospital at 1:38 PM on [DATE]. The hospital record reflected Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan, 24 hours nurses' notes, and nurses' notes reflected there was no information indicated that Resident #1's family member had requested to call them first before sending him out to the hospital when the resident had requested it. An interview on [DATE] at 2:04 PM, the DON revealed ADON E found Resident #1 unresponsive on the morning of [DATE] and initialed CPR (Cardiopulmonary resuscitation (CPR) is an emergency procedure that can help save a person's life if their breathing or heart stops immediately). Then, Resident #1 was transferred to the hospital after paramedic (an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system) revived him. An interview on [DATE] at 12:10 PM, the DON stated she expected all the nurses to assess the residents first when reporting of change of condition or request to go to the emergency or hospital as soon as possible. The DON stated she was not aware of Resident #1's family member had requested to call them first when Resident #1 wanted to go to the hospital until today ([DATE]) from LVN C after inquiry. The DON expected for the staff to call the physician immediately to get more medical attention depending on the resident's significant condition to transfer. An interview on [DATE] at 2:11 PM, ADON E stated she found Resident #1 was unresponsive while checking on him during providing care to Resident #2 who was roommate of Resident #1 on [DATE]. ADON E stated she did not recall exact time that she found Resident #1 unresponsive and called for a code response. ADON E stated she checked Resident #1's pulse, but no pulse was identified. She stated she and the other nurses initiated CPR immediately. ADON E stated Resident #1's body was still warm. ADON E stated the nurses stopped compression and handed that over to paramedic team after they arrived at the resident room. ADON E stated the paramedic team had worked on him for about 30 minutes, then they got response of Resident #1's pulse, then Resident #1 was transferred to the hospital. ADON E stated she talked with the resident's family member later on that day ([DATE]) and was notified Resident #1 expired at the hospital around 2 PM on [DATE]. ADON E stated she had no knowledge about Resident #1 had requested to go to the hospital or emergency room prior to calling a code. ADON E stated she expected all nurses to start transferring or discharge to the hospital or emergency room when the resident requested without delay. At 11:24 AM on [DATE], ADON E stated she heard that LVN C said she needed to call Resident #1's family first before sending him out to the hospital on [DATE]. However, she was not aware of LVN C called Resident #1's family or not prior to response him CPR on [DATE]. ADON E stated the resident would have delay in receiving medical treatment when the resident requested to go to the hospital and the nurses did not do the transfer or discharge process immediately. An interview on [DATE] at 3:11 PM on [DATE], LVN D revealed she worked at the facility for two weeks as a wound care nurse. LVN D stated she worked at the facility on [DATE] and she stated Resident #1 coded while she was providing care for Resident #2 who was Resident #1's roommate. LVN D stated she did not recall exact time that Resident #1 was coded. LVN D stated she left the room after the paramedic team arrived in the resident's room on [DATE]. An interview on [DATE] at 3:29 PM on [DATE], the Administrator revealed he was aware of Resident #1 was coded on [DATE] and the nurses were working with him until paramedics arrived. The Administrator stated he knew that Resident #1 was transferred to the hospital after coding him, however, he did not know Resident #1 had requested going to the hospital or emergency room prior to coding him. The administrator stated the resident would not receive a proper medical treatment when they requested to go to the hospital and they were not sent out immediately or delay on sending them. An interview on [DATE] at 12:54 PM, the MD G stated she had received text message when Resident #1 was coded on [DATE]. The MD G stated she did not receive report about Resident #1's request for emergency or hospital transfer. The MD G stated the resident would be transferred to the emergency or hospital when the resident or their family member requested sending to the hospital even though the resident had stable condition. An interview on [DATE] at 11:50 AM on [DATE], LVN F stated he worked at the facility for six months. LVN F stated he normally assigned to take care of Resident #1; however, he did not work on [DATE] the day Resident #1 was coded. LVN F stated he was not aware he had to call his family first when Resident #1 had requested to go to the hospital. LVN F stated he would not wait to transfer or discharge the resident when they requested to go to the emergency or hospital. If needed, he would call the family member first and sent them out without delay. LVN F stated he was aware of resident rights to be honored when requesting going to the emergency or hospital. Record review of the facility's policy on Transfer/Discharge of a Patient reflected, Purpose: To transfer and/or discharge a patient from the facility with the least amount of trauma and maximum amount of care and dignity. Procedure: 1. Notify attending Physician, family, or responsible party. Record review of the facility's policy on Transfer and Discharge reflected, Transfer and discharge requirements: The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 6. The resident or resident representative requests a voluntary transfer or discharge. Notice Before Transfer or Discharge: Before a resident is transferred or discharged , the facility will notify the resident and the resident representative about the transfer or discharge. This notice shall be in a language and manner they understand. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:14 PM. The IJ template was provided to the Administrator on [DATE] at 4:14 PM. The Plan of Removal was accepted on [DATE] at 4:26 PM and revealed: Purpose: The purpose of this action plan is to take steps to remove the immediate jeopardy in failing to ensure a resident was sent to the emergency room when Resident # 1 requested several times on [DATE]. On [DATE], Resident # 1 reported to a Speech Therapist # 13 [ST B] and a C.N.A. # 12 [CNA A] that he was not feeling well and requested to be sent to ER. LVN Charge Nurse # 6 [LVN C], assessed resident, obtained full set of V/S to include blood sugar, noted resident to be in stable condition. LVN Charge Nurse # 6 [LVN C] questioned resident if he would like to go to scheduled physician appointment or to be sent to hospital, resident responded to go to hospital. Per family request, LVN Charge Nurse # 6 [LVN C] informed resident that she would call family to notify them of request to be sent out to hospital, resident responded stating okay. Resident coded prior to being sent out. Action Plan incorporated to ensure systems are in place to ensure correction and removal of the Immediate Jeopardy: 1. RN DON # 1 [DON], RN # 2 [RN Z] , LVN # 3 [ADON S], LVN # 4 [ADON E], LVN # 5 [LVN Z] , LVN # 6 [LVN C], LVN # 7 [LVN F], LVN # 8 [LVN AA] and LVN # 9 [LVN BB] on [DATE] at 4:50 p.m [PM]. immediately assessed all current residents in the facility for any condition changes or any immediate medical issues that would warrant emergency transfer to the hospital to include asking the resident if they request a transfer to a hospital. These assessments will include a thorough head to toe assessment to include vital signs; blood pressure, temperature, respiration, oxygen sats, pain, neurological, cardiovascular, respiratory, GI/elimination, musculoskeletal, skin, & psychosocial. Any immediate assessments that are being done by the facility nurses that appear to indicate a change in a resident's condition or a medical emergency, the attending physician and the family will be notified by the RN DON # 1 [DON] for further orders and disposition. These head-to-toe assessments were completed on [DATE]. Results of all head-to-toe assessments and observations indicated no signs of any changes in conditions or the need for emergency medical assistance that would warrant a transfer to a hospital. 2. RN DON # 1 [DON] conducted an in-service training on [DATE] all licensed nurses, CMAs, and CNAs on identifying and reporting resident changes in condition and reporting to the physician any changes in condition. Staff not present for the [DATE] in-service training will be in-service trained on [DATE] and completed before that staff individual is allowed to start their work shift. All newly hired nursing personnel will be trained at their Orientation to the facility on resident changes of conditions and reporting these changes to their charge nurses where further reporting will be to the resident's attending physician for appropriate disposition to include any transfers to the local hospital. Examples of changes in condition were presented in the training sessions along with verbal interaction to confirm the understanding, importance and competency of the training. The following training was competed for all facility licensed nurse and a Post Evaluation test was administered to verify competency: Detecting Changes in a Resident's Condition; Know the Resident's Normal (Baseline) Condition; Recognizing Change: Top 12 Changes in Residents; and Responsibility for Observation & Reporting. 3. If a resident request to go to the hospital the facility will contact the attending physician and family and send the resident directly to the hospital as requested. Action plan to be incorporated to ensure systems are in place to monitor corrections. The administrator and the RN DON # 1 [DON], starting [DATE] and going forward, will review all 24-hour reports at the facility's daily stand-up meetings, which are current daily on-going meetings, to ensure that any and all changes of conditions were addressed and resolved. The administrator and the RN DON #1 will review and sign off on the reports to confirm that they were reviewed and acted upon if necessary. The Corporate RN # 10 [RN CC] starting, [DATE] will do monitoring with reviews of the 24-hour reports to ensure that all issues with resident changes in conditions are being documented and addressed. Included in these reviews the Corporate RN # 10 [RN CC] will randomly interview clinical staff on the items covered in the in-service training that was concluded on [DATE] and [DATE] to ensure that staff continue to be aware of changes in resident conditions and what the communication procedures are in documenting and reporting. These 24-hour reports will be scanned to the Corporate RN # 10 [RN CC] daily who will review each report and e-mail back to the facility administrator and the RN DON # 1 [DON] with comments or further action to be done. The RN DON #1 [DON] and the facility QAPI committee met and performed a Performance Improvement Plan (PIP) the Root Cause Analysis (RCA) of the deficient practice cited on [DATE]. The facility QAPI Committee will review and monitor weekly for the next month to ensure that the intervention plan is working as designed. The facility Medical Director # 11[MD G] was notified on [DATE] of the SQC/IJ and received a copy of this action plan on [DATE]. Administration and management are confident that the immediate jeopardy to any residents at [the facility] has been removed and addressed as of [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews were conducted on [DATE] with facility staff on all three shifts (LVN D, LVN H, LVN I, LVN J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA Q, CNA R, ADON S, LVN T, LVN U, CNA V, DM W, HS X, DOR Y, DON, and Administrator). The facility had a total of two different shifts [6 AM to 6 PM and 6 PM to 6 AM] for the nurses and had a total of three different shifts [6 AM to 2 PM, 2 PM to 10 PM, and 10 PM to 6 AM] for the other departments. Staff interviewed confirmed they received in-service training and were able to demonstrate how to identify the resident's change of condition and how to follow the facility protocol on emergency transfer when the resident had requested to go to emergency. Observations on [DATE] from 4:26 PM to 6:00 PM revealed no resident had been identified as having a change of condition and no delay on transferring or sending to the hospital identified. Interview with six alert residents [Residents, #2, #3, #4, #5, #6, and #7] on [DATE] from 5:00 PM to 5:30 PM revealed they did not have any issue to get a proper care including when they wanted to go to the hospital or emergency. An Immediate Jeopardy (IJ) was identified on [DATE]. The facility was provided with the IJ template on [DATE]. The administrator was informed the IJ was removed on [DATE] at 6 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm with a scope of isolated due to the facility's was still need to complete in-service training and evaluate monitoring the effectiveness of their corrective systems.