Every finding on record at Cypress Pointe Health & Wellness

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #121) reviewed for pain management. - RN B failed to administer Resident #121's Tramadol when she reported pain at 04 out of 10 and she requested the medication on 03/04/26.- RN B failed to complete a follow-up pain assessment after administering the resident 2 tablets of Acetaminophen 500 mg on 03/04/26. This failure could place residents at risk for decreased quality of life, uncontrolled, irretractable pain, and hospitalization. Findings included: Record review of Resident #121's Face Sheet dated 03/04/26 revealed, an [AGE] year-old female who admitted to the facility on [DATE]. There were no diagnoses listed on her Face Sheet. Record review of Resident #121's Social Worker admission Assessment and Interviews dated 03/04/26 revealed intact cognition as indicated by a BIMS score of 15 out of 15. Record review of Resident #121's undated Baseline Care Plan revealed, Health Conditions/Special Treatment- oxygen therapy, level of consciousness- alert and cognitive status- cognitively intact. Therapy Goals- improve functional status. Focus- risk of pain; Interventions- The resident will not have an interruption in normal activities due to pain through the review date, Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid,rocking, curled up, thrashing). Focus: the resident has oxygen therapy r/t chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (excess of carbon dioxide in the blood); Intervention: Oxygen settings per MD orders. Record of Resident #121's Hospital Records dated 03/1/26 revealed,- Tramadol tablet 50 mg Dose: 50 mg Dose: 1 tablet Dose: 50 mg Freq: every 6 (six) hours as needed Route: oral Start: 02/28/2026 Admin Instructions: 50 mg, oral, every 6 hours PRN, moderate pain (score 4-6).- acetaminophen (TYLENOL) tablet 650 mg Dose: 650 mg Dose: 2 tablet Dose: 650 mg Freq: every 6 (six) hours as needed Route: oral. Admin Instructions: 650 mg, oral, every 6 hours PRN, mild pain (score 1-3). Record review of Resident #121's Order Summary Report dated 03/04/26 revealed, - Assess Resident Level of Pain every Shift on 0-10 (least to greatest) Scale . USE 0-10 SCALE(A)FOR ALERT RESIDENTS. - Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for mild pain.- Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for moderate (pain). Record review of Resident #121's Pain Level Summary dated 03/04/26 revealed, 3/3/2026 09:16 PM, Value:0, Scale: Numerical3/4/2026 01:52 AM, Value:0, Scale: Numerical3/4/2026 10:33AM, Value:0, Scale: Numerical, Recorded by RN B3/4/2026 10:33AM, Value:4, Scale: Numerical, Recorded by RN B3/4/2026 01:09PM, Value:0, Scale: Numerical, Recorded by RN B Record review of Resident #121's PT Evaluation & Plan of Treatment dated 03/04/26 revealed, Additional Abilities/Underlying Impairment, Pain at Rest- intensity 5/10 (physical therapy) reports she just took pain meds); Frequency/Duration- intermittent, Location; R LE, Pain Description/Type- Aching. Pain with movement- Intensity: 5/10; Frequency/Duration- intermittent, Location; R LE, Pain Description/Type- Aching. Pain Assessment- Pain Assessment Method- patient verbalized pain level; does pain limit patient's functional activities?= YES. Record review of Resident #121's MAR printed on 03/04/26 at 02:07 PM revealed, - Resident #121 had not received any Tramadol since admission on [DATE].- Resident #121 received her first dose of Acetaminophen 500 mg on 03/04/26 at 10:33 AM. Her Pain level was reported as a 4 and the dose was documented as effective by RN B. Record review of Resident #121's Progress Notes printed 03/04/26 at 02:08 PM revealed,03/03/26 at 09:45 PM, Resident arrived @ 8:45pm transported via ambulance via stretcher by 2 EMS staff. Resident remained on skilled nursing services. Vital signs completed. Medication administered as ordered. Bed in lowest position and call light within reach. 03/04/26 at 01:21 AM, Resident observed resting in bed with eyes opened, pleasant lady, able to make needs known. A&O X4 (patient is fully awake, alert, and aware of four key areas: person, place, time, and event). Denies pain or discomfort at this time. Vitals obtained and recorded Temperature 97.4 BP140/62 p 82 o2 sat 95% on 2/L. ADLs completed, call light within reach, bed in the lowest position. Plan of care ongoing. An observation and interview on 03/04/26 at 10:13 AM revealed Resident #121 in bed as she received oxygen via nasal canula. She said her pain level ranged from 5 to 6 out of 10, and the pain stemmed from when she received incontinence care and she was rolled onto her hip. Resident #121 said she told staff it hurt during incontinence care and she had not received any pain medication since she admitted to the facility and she was supposed to receive tramadol. A grimace was not observed on Resident #121's face. In an interview on 03/04/26 at 10:20 AM, the state surveyors notified RN B of Resident #121's reported pain. RN B said she was not notified by any staff or the resident about the reported pain. In an observation and interview on 03/04/26 at 01:49 PM, Resident #121 reported pain at 4 to 5 out of 10 at rest that increased to 7 with movement. She said after she spoke to the surveyors in the morning, RN B talked to her about her pain but she was only administered 2 tablets of acetaminophen 500 mg. Resident #121 said at the hospital she received 50 mg and asked RN B for Tramadol, but RN B said she could only administer acetaminophen because to get approval from the physician to administer Tramadol to Resident #121. She said she was not offered any non-pharmacological (non-medication) options to control her pain and breathing exercises and repositioning helped manage her pain. Resident #121 said overnight her pain was so bad it woke her up and the pain sprung up and down with movement. She said after she received 2 tablets of acetaminophen, the nurse did not follow up with her to see if the treatment was effective, she continued to be in pain and distracted herself with her tablet. During the interview Resident #121 facial expressions and body language showed slight distress and discomfort. She could not confirm if she notified the night nurse of her pain overnight. In an interview on 03/04/26 at 02:42 PM, RN B said she was first notified of Resident #121's pain by the surveyor on the morning of 03/04/26 and the night nurse did not report the resident had pain She said during her morning round she made sure to check on the resident, since she knew Resident #121 was a new resident so she made sure to communicate with the resident who did not report any pain. RN B said after notification by the surveyor, Resident #121 reported pain at 3 to 4 out of 10 and informed the nurse she normally received tramadol. She said even though the resident had orders for tramadol, the reported pain scale of 3 to 4 and her assessment of the resident's facial expressions, indicated Resident #121 did not need tramadol so she offered her acetaminophen first. RN B said after she administered acetaminophen to Resident #121, she did not hear any complaints from her, she never pressed her call bell and when she provided care to Resident #121's roommate she observed Resident #121 to be in no immediate distress. She said mild pain was on a scale of 1 to 3 out of 10, moderate was 4 to 6 out of 10, and severe was 6 to 10 out of 10. RN B said Resident #121 informed her that her pain resulted from turning and repositioning that occurred during therapy. She said she did not perform any turning and repositioning, and when she returned to talk to the resident, she did not ask Resident #121 about her pain level and the resident did not report it so she documented it as a 0. RN B said nurses were expected to manage residents' pain by monitoring them during rounds, asking specific questions about pain and completing a follow-up assessment following the administration on pain medication to determine effectiveness. RN B said she did not ask Resident #121 about her pain because she saw the resident scrolling on her tablet so she used her expressions to determine effectiveness. She said it was a mistake and she should have asked Resident #121 if her pain was controlled after she received acetaminophen. She said failure to administer appropriate pain medication or complete follow up pain assessments place residents at risk of continuation or worsening of pain, discomfort and the ability to complete therapy. In an interview on 03/06/26 at 01:23 PM, the DON said nursing staff were expected to assess residents' pain on each shift, especially if they had an order for pain medication or pain assessments. She said when staff administered any pain medication they must do a follow up assessment 30 minutes to 1 hour after administration and it should be documented in the MAR. The DON said a resident with a BIMS score of 15 should be interviewed and a numerical pain scale should be used. She said mild pain was 1-4, moderate was equal or greater than 4 and when a resident was on the border their preferences should be followed. She said failure to complete a follow up assessment or administer the preferred/appropriate medication placed residents at risk of uncontrolled pain and the facility would not know if the administered pain medication as effective. The DON said pain management was important and staff should push administration of appropriate medication to make sure therapy was successful because with the exercise you are going to see it [pain]. She said RN B should not have documented a follow-up pain score of 0 for Resident #121 when she did not assess her because inaccurate documentation could place residents at risk uncontrolled pain. In an interview on 03/06/26 at 02:56 PM, Resident #121 said she did not need any pain medication at that time, her pain was at baseline and she had received her tramadol. She said she just wanted to break the pain cycle with tramadol and once it was under control she would take acetaminophen. Record review of RN B's Skills Competency Assessments revealed,- On 08/14/25 she acknowledged training on Pain management - pain assessment every shift and PRN - must have pain level. Record review of the facility policy titled System Pathways #4- Pain Management dated 2022 revealed, The community is to recognize the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The community should: evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a Care Plan for pain management. MONITORING Pain & Medication Effectiveness: Pain should be monitored by the assigned nurse for the resident. Resident MD/NP orders will have the order for Pain Assessment.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 5 of 5 medical supplies, (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) reviewed for medication storage and labeling.The facility failed to ensure the medication room was free from expired medical supplies on [DATE].This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition (change of a substance into something else, often making it weaker, useless, or harmful), and could cause infections due to compromised sterile equipment.Findings included: During an observation of 300 hall's medication cart and interview on [DATE] at 10:28 a.m., revealed staff stored expired eSwab tubes (a system of a liquid-based, FDA-cleared device for collecting and transporting wound cultures) count 2, both expired on [DATE]. LVN J stated he checked the medication cart every day for expired items. He stated he should have noticed the expired tubes and discarded them. LVN J stated leaving expired unopened wound culture tubes in medication carts could cause inaccurate lab results and improper treatment plans based on those wrong results.During observation of the medication room and interview with ADON B on [DATE] at 10:35 a.m., revealed, staff stored the following expired medical supplies:- Unopened eSwab tubes count 7, all expired on [DATE].- Unopened eSwap tubes count 2 expired on [DATE].- Unopened 20 urine analysis transfer straw kits (used to move urine from a collection cup into test tubes to test it) count 20 expired in February 2026.- Unopened flu test kits count 90 expired on [DATE].- Unopened gastric (in the stomach) feeding tubes count 3 expired on [DATE], [DATE], [DATE].- Unopened intravenous ( in the vein) administration sets count 40 expired on [DATE]. ADON B stated staff did not use those tubes recently. She stated she checked the medication room every month for expired items but did not notice the expired items. She stated using expired medical supplies could cause inaccurate laboratory results, improper treatment plans and infections.During an interview on [DATE] at 12:00 p.m., the DON stated she expected ADON B to check the medication room every month and expected nurses sand MAs to check medication carts every day for expired items. She stated she did random audits every week on medication carts and the medication room for expired items. The DON stated using expired medical supplies could cause inaccurate laboratory results, improper treatment plans and infections.Record review of the facility's, undated, Medical Supplies Inventory Policy revealed .1. It should be best practice to rotate supplies and move older supplies to the front and use first. 2. Such practices help with reducing waste and the likelihood of expired products being used. 3. Conducting regular audits such as at least monthly the medical supply person/designee maintains oversight of medical supplies and their expiration dates/status. These audit checks should be scheduled at consistent intervals, any supplies nearing their expiry dates are identified and addressed promptly. 4. Direct care staff should look at medical supplies before use and if expired date is noted it is to be thrown away and obtain another item that is not expired. 5. Direct care staff should notify the DON and medical supply person if an expired item is found to help consider conducting an audit sooner that monthly occurrence.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. -The facility failed to ensure food items were labeled and dated. This failure could place residents at risk of foodborne illness and disease.Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure food items were labeled and dated. This failure could place residents at risk of foodborne illness and disease. Findings include: Observation of the facility's kitchen on 3/4/2026 at 8:18 a.m. revealed the following: An open container of Homestyle Mayonnaise, 1 gallon, in the refrigerator were not dated. In an interview on 3/6/2026 at 10:18 a.m. with the Kitchen Manager, she stated everything in the refrigerator was labeled except the mayonnaise. She stated she did not know why the mayonnaise was not labeled, it was possibly overlooked. She stated it was the kitchen staff and her responsibility to ensure all food in the refrigerator were labeled. When asked if she understood the risk to the residents if the food in the refrigerator was not dated, she responded, Possibly not knowing how long the food is in the refrigerator. She stated the mayonnaise should have been discarded due to not knowing how long it had been in the refrigerator. Record review of the facility's Food Storage policy, revised on 6/1/2019, stated: d. Date, label, and tightly sealed all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.

Based on interview, observation and record review, the facility failed to ensure that assessments accurately reflected residents' status for 2 of 22 residents (Resident #2 and Resident #12) reviewed for accuracy of assessments. - The facility failed to ensure Section E of Resident #12's admission MDS completed on 02/27/26 accurately reflected her behaviors and rejection of care. - The facility failed to ensure Section I of Resident #2's Quarterly MDS completed on 01/13/26, Quarterly MDS completed on 10/13/2025, Annual MDS completed on 08/20/2025 accurately reflected her active diagnoses. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included:Resident #2 Record review of Resident #2's Face sheet dated 03/06/2026 revealed a 74- year- old female who admitted to the facility on [DATE] with diagnoses which included: vascular dementia(a brain condition caused by reduced blood flow, often from brain attack or damaged blood vessels, which deprives brain cells of oxygen) diagnosed on [DATE], paranoid schizophrenia (a chronic, severe brain disorder that causes people to interpret reality abnormally) diagnosed on [DATE]. Record review of Resident #2's Annual Comprehensive MDS dated [DATE] revealed the following: - Active diagnoses: staff marked schizophrenia as an active diagnosis. - Antipsychotic medication review: staff marked antipsychotics were not received. Record review of Resident's Quarterly MDS dated [DATE] revealed the following: - Active diagnoses: staff marked schizophrenia as an active diagnosis. - Antipsychotic medication review: staff marked antipsychotics were not received. Record review of Resident #2's Quarterly MDS dated [DATE] revealed the following: - Active diagnoses: staff marked schizophrenia as an active diagnosis. - Antipsychotic medication review: staff marked antipsychotics were not received. Record review of Resident #2's Hospital Discharge summary dated [DATE] revealed no diagnosis of schizophrenia and no order to start on antipsychotic medications. Record review of resident #2's Provider Orders dated 03/06/2026 revealed no active orders to receive antipsychotic medications. During an interview on 03/06/2026 at 11:35 a.m., the NP stated Resident #2 was not schizophrenic and did not need to be on antipsychotic medications. During an interview on 03/06/2026 at 12:28 p.m., MDS LVN A stated she referred to Resident #2's Diagnoses List, that she updated using Resident #2's admission Notes, to guide her in completing the resident's MDSs when they were due. She stated schizophrenia was a diagnosis that Resident #2 would not come out of, so she decided to use the diagnoses list. She stated she should have reviewed Resident #2's provider progress notes for a 7-day look back up-to-date diagnoses especially that Resident #2 was not actively receiving antipsychotic medications and that should have made her question the diagnosis of schizophrenia. MDS LVN A stated an inaccurate MDS could put residents at risk of being wrongly billed for diagnoses that did not exist. During an interview on 03/06/2026 at 12:40 pm, the DON stated she expected MDS LVN A to review the provider's notes to see the current diagnoses and use those diagnoses to complete resident #2's MDSs. The DON stated MDS LVN A should not have used Resident #2's Diagnoses List or keep updating the Diagnoses List without reviewing the recent Provider Notes to complete Resident #2's MDSs. The DON stated the Regional RN signed off on the residents' MDSs after the MDS LVNs completed their assigned MDSs. She stated inaccurate MDS could put Resident #2 at risk of wrong billing and improper treatment plan. The DON stated she shared the responsibility of signing off on the residents' MDSs with the [NAME] MDS RN, who signed off Resident #2's MDSs. During an interview on 03/06/2026 at 1:07 p.m., the Regional MDS RN stated she signed off on the residents' MDSs after the facility's MDS Nurses completed those MDSs. She stated signing off meant the MDS LVNs had the training they needed to complete the residents' MDSs. The Regional MDS RN stated she expected MDS LVN A to review the provider's notes to see the current diagnoses and use those diagnoses to complete Resident #2's MDSs. The Regional MDS RN stated MDS LVN A should not have used Resident #2's Diagnoses List to complete Resident #2's MDSs. She stated MDS LVN A should not have updated Resident #2's Diagnoses List in the first place without reviewing the recent Provider Notes for up-to-date diagnoses. She stated an inaccurate MDS did not affect Resident #2's care or medication regimen and did not cause wrong billing. The Regional MDS RN stated expected MDS LVN A to notice Resident #2's Dementia diagnosis on 08/20/2025 should have overruled (it refers to a situation where a new, often more senior or specialized, medical professional reviews a previous diagnosis and decides it is incorrect, invalid, or no longer applies) the schizophrenia diagnosis and removed the diagnosis from Resident #2's diagnoses List. Record review of the facility policy titled Minimum Data Set Process with no revision date revealed, Purpose: The long-term care facility follows CMS requires per RAI as a policy the facility completes an MDS and codes the Minimum Data Set (MDS) per the RAI manual and coding is based upon clinical assessments, interviews, interventions, etc. The following information can be utilized from the resident medical record to complete the MDS. a. Objective observations: b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition (also includes labs, radiology, etc.); e. Events, incidents or accidents involving the resident; and f. Behavioral concerns/issues progress toward or changes in the care plan goals and objectives. h. Treatment, Medication orders: new, changes, etc. I. Transfers, discharges. The RAI process has multiple regulatory requirements. [Federal regulations] require that (1) The assessment accurately reflects the resident's status, (2) A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, (3) The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. Resident #12 Record review of Resident #12's Face Sheet dated 03/05/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial infection in the blood), type 2 diabetes, difficulty swallowing, and mild dementia without behavioral disturbance. Record review of Resident #12's admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15. Section E- Behavior revealed: no potential indicators of psychosis (loss of contact with reality associated with hallucinations (sensing things that are not there), delusions (firm, false believe) and disorganized thinking); no physical behavioral symptoms directed towards others (hitting/kicking/scratching; no verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others); no other behavioral symptoms not directed towards others; and no rejection of care. Section E was completed on 02/27/26 and signed by MDS Nurse B. Record review of Resident #12's undated Care Plan revealed, Focus initiated on 02/23/26: resident has a behavior problem, refuses medications r/t dementia. The interventions included:- Administer medications as ordered. Monitor/document for side effects and effectiveness, If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Record review of Resident #12's Progress Notes revealed, - 02/20/26 at 03:29 PM signed by RN B revealed, Resident #12 transferred from [Hospital] via stretcher. On observation patient have hand medical hand mitts to prevent from interrupting treatment. patient observed refusing doing covid test but with help of two [medical transports] covid test performed. - 02/21/6 at 03:03 AM signed by RN I revealed, Resident is currently resting in bed comfortably with bed in a low position and call light within reach. Resident refused her medication this morning and RP was made aware. Resident kept shaking her head: no. - 02/24/26 at 05:39 AM signed by LVN E revealed, Behavior observed when providing ADLs. 2X (2 times per day) staff tried to provide ADLs and resident refused and attempt to hit. Resident refused taking her morning medication, Pantoprazole, Methocarbamol and Tylenol. This nurse attempt 2 times and informed RP about refusal. RP voiced he will be vising (holding) by 8am and try again. Will notify upcoming nurse to follow up with. - 02/24/26 at 03:37 PM signed by RN B revealed, patient have h/o refusing medication and food. RP are aware of it. Patient refuse morning medication. RP in the building and nurse talk to the family and with family member by side nurse succeed administering medication to patient. RP also stated they usually administer medication to patient and help her eat food too. nurse stated nurse/CMA will administer medication with family on patient side. DON/CMA made aware of it. - 02/24/26 at 05:57 PM signed by ADON C revealed, New order received for Psychological/Psych consult related to being combative - RP made aware. - 02/27/26 at 01:39 AM signed by LVN E revealed, Resident has refused drawing blood for the labs. - 02/27/26 at 06:47 AM signed by LVN E revealed, Behavior observed and refused morning medication. Refused ADLs . attempt twice to give medication and changed adults brief but resident has refused. Started acting agitating. An observation on 03/04/26 revealed, Resident #12 well dressed, in no immediate distress, and sitting in her room in a wheelchair. The resident was confused and did not respond to most of the surveyor's questions. In an interview on 03/06/26 at 02:00 pm, MDS Nurse B said she was responsible for the completion of Resident #12's MDS. She said the MDS was completed through observation, interviews and records review and she was responsible for ensuring the resident MDS(s) were accurate. MDS Nurse B said the information from the MDS was expected to reflect the resident in real time and in a look back period. She said while she did not remember Resident #12's behaviors, based on her review of the resident's progress notes the MDS dated [DATE] was inaccurate because it did not document the resident's behaviors and rejection of care. She said Section E should not have reflected no for behaviors and rejection of care.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 3 of residents (Resident #7, Resident #111, and Resident #121) reviewed for respiratory and tracheostomy care. - ADON C failed to assess Resident #7's respiratory status when he was observed with his oxygen mask off his tracheostomy tube.- RN B failed to assess Resident #7's respiratory status before and after performing tracheostomy ( a surgically created opening into the windpipe allowing breathing, bypassing upper airway obstructions) care on 03/04/26.- The facility failed to ensure Resident #7 received O2 as ordered when he was administered 4L instead of 6L as ordered.- The facility failed to ensure the oxygen mask was directly over Resident #7's tracheostomy tube.- RN B failed to assess Resident #111 when she was observed with her nasal canula (tube placed into the nose to provide oxygen) nose) off on 03/04/26.- ADON C failed to assess Resident #111 when she was observed with her nasal canula (tube placed into the nose to provide oxygen) nose) off on 03/05/26. - The facility failed to ensure Resident #121 received O2 as ordered when she was administered 2L instead of 5L as ordered. The failures could place residents at risk for respiratory distress and hypoxia (deficiency of oxygen). Findings Included: Resident #7 Record review of Resident #7's Face Sheet dated 03/05/26 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: respiratory failure with hypoxia, tracheostomy, type 2 diabetes, Parkinson's disease (progressive movement disorder caused by damage to brain nerve cells) and COPD (progressive irreversible lung disease that blocks airflow and makes breathing difficult). Record review of Resident #7's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no behaviors, no rejection of care, maximum assistance with upper body dressing and total dependence for: eating, bathing, lower body dressing, personal hygiene, roll left to right, move from sit to lying & lying to sitting on side of bed. Tracheostomy status, shortness of breath, respiratory treatments of: continuous oxygen, suctioning and tracheostomy care. Record review of Resident #7's undated Care Plan revealed, Focus: The resident has oxygen therapy r/t emphysema (chronic incurable lung disease, part of COPD, that results from damage to air sacks causing severe breathing difficulty, wheezing and fatigue) / COPD; Interventions- Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis (profuse, excessive sweating occurring without physical exertion), Headaches, Lethargy, Confusion, Atelectasis (partial or complete collapse of a lung or its lobes), Hemoptysis (coughing up blood or blood stained mucus from lungs), Cough, Pleuritic pain (sharp, stabbing chest pain), Accessory muscle usage, Skin color. Oxygen settings per MD orders. Focus: The resident has a tracheostomy r/tImpaired breathing mechanics; Interventions- Ensure that trach ties are secured at all times, Monitor/document respiratory rate, depth and quality. Check and document q shift/as ordered, oxygen settings: see MD orders. Record review of Resident #7's Order Summary dated 02/20/26 revealed, O2 @ 6 (critically low and incompatible with life) via trach to maintain sats (oxygen saturation) above 92%. The order was discontinued on 03/05/26. Record review of Resident #7's Order Summary Report dated 03/05/26 at 01:54 PM revealed,- Suction trach as needed for airway clearance.- O2 @ 4L via Trach to maintain sats above 92%. Every shift for Hypoxia with order start date of 03/05/26.- Trach care HS shift & PRN as needed An observation on 03/04/26 at 10:49 AM revealed Resident #7 lying in bed, well-groomed and in no immediate distress; his breathing was unlabored and rate was normal. The resident had a trach collar (a device worn around the neck to secure a tracheostomy tube in place, preventing dislodgement), his oxygen concentrator delivered O2 at 4 L/min and the oxygen mask was not over his trach. The surveyor alerted ADON C, who entered the room, cleaned Resident #7's trach collar with a towel that sat on his chest and placed the oxygen mask over Resident #7's trach collar. She did not assess Resident #7's blood oxygen levels with a pulse oximeter. Resident #7 coughed as ADON C provided care, so she said she would get his nurse to perform trach suctioning. An observation on 03/04/26 at 10:58 AM revealed RN B entered into Resident #7's room to suction the resident's trach. She gathered her supplies, turned on the machine and began to suction the resident after telling him what she was going to do and instructed him to alert her if he had any discomfort. She did not check Resident #7's oxygen saturation before or after suctioning the resident. Resident #7 was observed to be in no respiratory distress when he was suctioned and had unlabored breathing. Record review of the facility policy titled Suctioning the Lower Airway (Endotracheal [ET] or Tracheostomy Tube) revised 10/2010 revealed, Purpose: The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract. General Guidelines: 1. Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia, hypoxemia (below normal concentration of oxygen in the arterial blood), and cardiac dysrhythmias-irregularity on heart rate (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines: a. Suction only as needed, based on assessment of the resident's level of respiratory distress; b. Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.); c. If resident has order for O2 - Apply oxygen to help oxygenate resident before and after suctioning 2. Monitor the resident's pulse and oxygen saturation (Pulse Oximetry) before and after the suctioning. If pulse decreases more than 20 beats per minute (BPM) or increases more than 40 BPM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re-ventilate and re-oxygenate the resident. Resident #111 Record review of Resident #111's Face Sheet dated 03/06/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: presence of a pacemaker, stomach bleed, falls, long term use of blood thinners and high cholesterol. Record review of Resident #111's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, no behavioral symptoms or rejection of care, use of a walker and wheelchair, total dependence for must ADLs and oxygen therapy while a resident in the facility. Record review of Resident #111's undated Care Plan revealed, Focus- The resident has a behavior problem(removing her clothing, oxygen and foley) r/t Dementia revised 03/04/26; intervention- Psych consult 2/5/26 Date Initiated: 02/10/2026. Focus- The resident has oxygen therapy r/t CHF - resident sometimes removes oxygen and needs reminded she needs to wear it, revised 03/04/26; Interventions: Oxygen settings per MD orders Date Initiated: 01/14/2026, Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis (sweating), Headaches, Lethargy (tiredness), Confusion. Record review of Resident #111's Order Summary Report dated 03/06/26 revealed, - O2@ 2L via NC CONTINUOUS every shift.- oxygen 2L via NC as needed to maintain oxygen >92% every shift for desaturation (dangerous drop in blood oxygen level dipping below 90% and signaling potential respiratory or cardiac issues). Record review of Resident #111's O2 Sats Summary dated 03/06/26 revealed,3/1/2026 09:08 98.0%3/1/2026 8:42 pm 96.0%3/2/2026 1:23 am 96.0%3/2/2026 7:52 am 96.0%3/2/2026 2:32 pm 96.0%3/2/2026 11:56 pm 96.0%3/3/2026 6:58 am 96.0%3/3/2026 9:59 pm 98.0%3/4/2026 1:50 am 96.0%3/4/2026 7:04 am 96.0%3/4/2026 11:15 am 98.0% @ 2 L/Min3/4/2026 3:56 pm 98.0%3/5/2026 12:18 am 97.0%3/5/2026 9:48 pm 97.0%3/5/2026 11:31 pm 97.0% Record review of Resident #111's Progress Notes revealed, - 03/04/26 at 11:15 AM, patient removed her oxygen via nasal canula. Nurses reconnected oxygen as soon as possible. No sign of distress, shortness of breath, labored breath noted. Nurse comforted the patient, patient didn't complain of distress and discomfort. RP in the building and notified. RP stated understanding. Will continue monitoring patient for oxygen saturation and discomfort. Will continue plan of care.- 3/5/2026 05:39 AM, Resident observed removing her NC multiple times and this nurse placed it back and O2 saturation monitored every time she has removed her NC. O2 saturation maintained 97%. An observation on 03/04/26 at 09:57 AM revealed Resident #111 in bed. Her oxygen canula was out of her nose, in her hand and the resident appeared sedated. She was drifting in and out, not interviewable, could not keep her eyes open and was confused. The surveyor immediately notified RN B, who entered the resident's room, placed the nasal canula in the resident's nose and left the room after talking to the resident. She did not perform any assessments on Resident #111, and did not check the resident's blood oxygen saturation level or oxygen settings. An observation on 03/05/26 at 09:57 AM revealed Resident #111 eating breakfast with her nasal canula out of her nose. She was responsive to the surveyor's questions and was not in respiratory distress. The surveyor immediately notified ADON C, who entered the resident's room, placed the nasal canula in the resident's nose and left the room after talking to Resident #111. She did not perform any assessments on Resident #111, and did not check the resident's blood oxygen saturation level or oxygen settings. In an interview on 03/04/26 at 02:42 PM, RN B said nurses were expected to assess residents who received O2 every shift to ensure it was administered as ordered. She said when she was notified by the surveyor she failed to check Resident #111's sats because it happened too fast. She said failure to check oxygen saturation levels of residents who were found without their continuous oxygen placed them at risk of difficulty breathing, and hypoxia. Resident #121 Record review of Resident #121's Face Sheet dated 03/04/26 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses. There were no diagnoses listed on her Face Sheet. Record review of Resident #121's undated Baseline Care Plan revealed, Health Conditions/Special Treatment- oxygen therapy, level of consciousness- alert and cognitive status- cognitively intact. Therapy Goals- improve functional status. Focus- risk of pain; Interventions- The resident will not have an interruption in normal activities due to pain through the review date, Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid,rocking, curled up, thrashing). Focus: the resident has oxygen therapy r/t chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (excess of carbon dioxide in the blood); Intervention: Oxygen settings per MD orders. Record review of Resident #121's Order Summary Report dated 03/04/26 revealed, - O2 @ 5L VIA Nasal Cannula to maintain sats above 92% every shift for hypoxia/ copd. Record review of Resident #121's Progress Notes revealed,03/04/26 at 01:21 AM, Resident observed resting in bed with eyes opened, pleasant lady, able to make needs known. Alert &Oriented X4. Denies pain or discomfort at this time, but ask that we bear with her as she just lost her [partner] in January and still grieving. Vitals obtained and recorded Temperature 97.4 degrees Fahrenheit, BP 140/62, p 82, O2 sat 95% on 2/L. An observation on 03/04/26 at 10:13 AM revealed Resident #121 was in bed with a nasal cannula in place that administered oxygen at 2L/min. She was in no respiratory distress, her breaths were unlabored. An observation and interview of 03/04/26 at 01:45 PM revealed Resident #121 in bed with a nasal canula in place that administered oxygen at 2 L/min. She said she never received oxygen at 5 L/min, had not experienced any respiratory distress and her oxygen saturation was always between 97-100 %. In an interview on 03/06/26 at 10:05 AM, RN B said Resident #7 had limited ability to move his neck since he had the trach placed. She said the resident's oxygen mask should always be over his trach and she did not know it was off prior to ADON C requesting her to perform trach care on 03/04/26. RN B said nurses must check O2 sats, before, during and after trach care to ensure the resident received enough oxygen. She said she failed to check Resident #7's O2 sats when she provided trach care because she was just freaked out. RN B said if a resident failed to have their ordered continuous oxygen in place they could experience hypoxia so it was importance to check their saturation levels after reapplying the oxygen. She said she never observed Resident #7, Resident #111 or Resident #121 in respiratory distress on 03/04/26. In an interview on 03/06/26 at 11:55 AM, ADON C said Resident #7 had limited mobility of his head, neck, shoulder and arms. She said he required continuous oxygen via his trach and prior to performing trach care and suctioning staff must check the resident's oxygen saturation with a pulse oximeter to ensure they are adequately oxygenated. She said oxygen must be administered as ordered by the physician and if a resident that required continuous oxygen was found without their oxygen delivery device (nasal canula or mask) in place by staff, the staff must first apply the residents device as ordered and then check for their oxygen saturation to ensure they were ok. ADON C said if a resident failed to receive continuous oxygen as ordered they could desaturate, have difficulty breathing and experience respiratory distress (critical condition marked by difficulty breathing, rapid heart rate, and increased respiratory effort). She said failure to assess residents who experienced interrupted oxygen delivery would place the resident at risk of unknown blood oxygen levels. In an interview on 03/06/26 at 01:23 PM, the DON said Resident #7 had a stable tracheostomy, had no complaints of shortness of breath and required continuous oxygen. She said when staff performed trach care they were expected to hyperventilate the resident by increasing their oxygen administration to 4-5 L/min and monitor oxygenation before, during and after trach care such as suctioning to ensure the resident received sufficient oxygen. She said failure to monitor oxygenation during trach care could place residents at risk of hypoxia and respiratory distress. The DON said when a resident was found without their oxygen delivery device on staff were expected to apply the device and then check the residents O2 sats to know their blood oxygen levels. She said she should not apply the mask and leave the resident unattended because the resident's respiratory status was unknown and they may experience a change of condition. The DON said oxygen should be administered as ordered and nursing staff were expected to check the administration rate against the TAR and check the residents oxygen saturation rate. She said failure to administer oxygen as ordered could place residents at risk of SOB and hypoxia. Record review of RN B's Clinical Nursing Validation Review Checklist dated 08/14/25 revealed, she was assessed for:- Infection Control- sharps disposal- Respiratory- pulse oximeter, oxygen mask/nasal canula, tracheal suctioning, trach care. The competencies were met. Record review of ADON C Clinical Nursing Validation Review Checklist dated 02/20/26 revealed, she was assessed for:- Respiratory- pulse oximeter, oxygen mask/nasal canula, tracheal suctioning, trach care. The competencies were met. Record review of the facility policy tilted Oxygen Administration with no revision date revealed, Purpose: A resident will receive oxygen therapy when ordered by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration. 5. Monitor the resident's response to oxygen therapy. Check pulse oximetry as indicated if ordered by physician/FNP or change in condition. 6. Monitor the resident for signs of hypoxemia as appropriate, such as: a. level of consciousness, b. pulse oximetry, c. vital signs, d. skin and mucous membrane color , e. breathing patterns, f. dyspnea, g. cyanosis, cool, clammy skin. 2. Record review of Resident #57's face sheet, dated 03/05/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: respiratory failure, high cholesterol, paralysis of the left nondominant side following a stroke (brain damage caused by the cut off of blood), blood infection and diarrhea.Record review of Resident #57's admission MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 03 out of 15. Resident #57 used a wheelchair and had no behaviors or rejection of care.Record review of Resident #57's, undated, Care Plan revealed, Focus- altered cardiovascular status due to history of stroke, high cholesterol and hypertension (high blood pressure). Record review of Resident #57's Order Summary Report, dated 03/05/26, revealed Accucheck (blood sugar check) AC/HS. Record review of Resident #57's Blood Sugar Summary, dated 03/05/26, revealed RN checked Resident #57's blood sugar on 03/04/26 at 08:33 AM. The reading was 109 mg/dL.An observation and interview on 03/04/26 at 09:44 AM revealed, Resident #57 in a wheelchair accompanied by a family member in the resident's room. There was a white and purple lancet on the nightstand located on the left side of the resident's bed, the safety cover of the needle was absent, the purple button was depressed and the hole containing the retracted needle was visible. Resident #57 and his family were unaware of the lancing device.In an observation and interview on 03/04/26 at 09:45 AM, the DON was notified of the presence of the unused lancing device. She entered into Resident #57's room, retrieved the lancing device and discarded it in the sharps container affixed to the wall in the inside of the resident's room.In an interview on 03/04/26 at 10:05 AM revealed, RN B said she checked Resident #57's blood sugar on the morning of 03/04/26. She said when a nurse checked a resident's blood sugar they were expected to discard the disposable lancet after the blood sample was retrieved and applied to the glucometer (device used to measure blood sugar) and the lancet should never be left unattended. RN B said she did not use the white and purple lancet observed in Resident #57's room in the morning but all staff who entered a resident's room should make rounds to ensure there were no safety concerns. She said an unattended lancet could place residents at risk of injury or infection if already used.In an interview on 03/06/26 at 01:23 PM, the DON said a used lancet should not be left unattended and must be discarded in a sharps container immediately. She said an unattended lancet could place residents at risk of injury if they pricked themselves with it and infection control if it was used.Record review of the facility's policy and procedures on Suctioning the Lower Airway (Endotracheal [ET] or Tracheostomy Tube) (revised October 2010) read in part: The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Assemble the equipment and supplies as needed.Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).The following equipment and supplies will be necessary when performing this procedure: Sterile suction catheter kit; Sterile drape; Sterile cup; Sterile gloves; #10 to #16 French [size] catheter; Sterile gauze; Sterile saline or sterile water.Perform hand antisepsis. Put on gloves. Turn on suction unit and adjust to appropriate negative pressure. Remove gloves. Open suction catheter kit. Place sterile drape across the resident's chest. Remove sterile cup, touching only the outside. Fill cup with sterile saline or sterile water. Apply sterile gloves. Recommend: The dominant hand will remain sterile. Holding the catheter in dominant hand and the tubing in the non-dominant hand, connect the catheter to the tubing. Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit). Remove oxygen or humidity delivery device using non-dominant hand. Instruct the resident to inhale. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME] [base of windpipe where it splits into left and right lung). Pull back 1 to 2 cm. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than 10 seconds. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions. Rinse catheter and tubing with sterile saline or sterile water until clear.Limit suction passes to a maximum of three.Record review of the facility's policy and procedure on Tracheostomy Care (revised August 2013) read in part: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Open tracheostomy cleaning kit. Set up supplies on sterile field. Maintaining sterile field.Open four gauze pads and saturate with hydrogen peroxide. Open two gauze pads and saturate with antiseptic solution. Open two gauze pads and saturate with sterile saline. Open two gauze pads; keep them dry. Put on sterile gloves. Secure the outer neck plate with non-dominate gloved hand. Unlock the inner cannula with gloved dominate hand. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Remove and discard gloves into appropriate receptacle. Wash hands and put on fresh gloves. Replace the cannula carefully and lock in place.Apply clean gloves. Clean the stoma with two peroxide-soaked gauze pads (using a single sweep for each side). Rinse the stoma with saline-soaked gauze pads (using a single sweep for each side). Wipe with dry gauze (using a single sweep for each side). Apply a fenestrated gauze pad around the insertion site.Record review of the facility's policy titled Blood-Sampling- Capillary (Finger Sticks revised 09/2014 revealed, Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees . Steps in the Procedure: 5. Wipe the area to be lanced with an alcohol pad/wipe. 6. Obtain the blood sample, following the manufacturer's instructions for the device. 7. Discard lancet and platform into the sharps container . Record review of the facility's policy and procedures on Infection Prevention and Control Program (revised August 2016) read in part: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures.prevention of infection .The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).Important facets of infection prevention include:.educating staff and ensuring that they adhere to proper techniques and procedures.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1of 3 (Resident #70) residents reviewed for parenteral fluids. - The facility failed to ensure the dressing of Resident #70's IV line was changed weekly as ordered. This failure could place residents at risk for unwanted infections and further decrease in quality of life. Findings included: Record review of Resident #70's Face Sheet dated 03/05/26 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: skin infection (cellulitis) of the left upper limb, type 2 diabetes, anxiety and obesity (excessive fat accumulation). Record review of Resident #70's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, no indication of hallucinations (feeling things that aren't there), delusions (firm believes that are not real), no behavioral symptoms and rejection of care that occurred 1 to 3 days, surgical wounds, application of nonsurgical dressings, antibiotic use and IV access while a resident at the facility. Record review of Resident #70's undated Care Plan revealed, Focus- risk for complications associated with antibiotic IV therapy related to left upper arm cellulitis. The interventions included- Change dressing to IV access site as ordered. Focus- resistance to care r/t adjustment to nursing home. The interventions included- Give clear explanation of all care activities prior to an as they occur during each contact. Record review of Resident #70's Physician's order on 03/01/26 revealed, PICC line (a long thin, flexible tube inserted through a vein in the upper arm for longterm intravenousaccess for medications, fluids, or blood draws) dressing and cap change weekly using sterile technique per protocol: in the morning every sun for dressing change. Record review of Resident #70's Temperature Summary dated 03/05/26 revealed no documented fever (rise in body temperature over 100.4 degree F).3/1/2026 01:25 AM 98.8 F3/1/2026 08:45 AM 97.8 F3/1/2026 08:56 PM 98.7 F3/2/2026 01:26 AM 98.8 F3/2/2026 07:54 AM 97.2 F3/2/2026 09:54 AM 97.2 F3/2/2026 09:29 PM 97.8 F3/2/2026 11:52PM 97.7 F3/3/2026 12:38 PM 97.8 F3/3/2026 04:51 PM 97.8 F3/4/2026 01:47 AM 97.7 F3/4/2026 01:50 PM 97.4 F3/4/2026 05:20 PM 97.7 F3/5/2026 12:23 AM 98.0 F Record review of Resident #70's March 2026 MAR revealed, LVN J documented the dressing on Resident #70's PICC line was changed on Sunday, 03/01/26. Record review of Resident #70's Progress Notes revealed,-03/01/26 at 08:32 AM signed by the RN, Resident is currently resting in bed comfortably with bed in a low position and call light within reach. No current distress or pain observed. Resident is adjusting to facility well. Resident is tolerating PT and OT well. Residents peripheral IV site has a dressing that is clean, dry and intact. No s/s of pain or infiltration to site area. No s/s of infection observed to site area.There was no documentation regarding the change of Resident #70's PICC line dressing or the resident rejecting the dressing change. An observation and interview on 03/04/26 at 10:29 AM revealed, Resident #70 was in no immediate distress in bed. The resident had a dressing on her right upper arm covering a PICC line and a dressing on her left shoulder. The dressing on the right arm was clean and read 02/22/26, while the dressing on the left arm read 03/03/26. Resident #70 said she received IV antibiotics for a bacterial skin infection in her left shoulder and she didn't know the last time her IV dressing was changed but the line stopped working so it was scheduled to be changed. There was no redness or swelling observed around the area of the IV dressing. In an interview on 03/06/26 at 10:05 AM, RN B said nurses were expected to check residents' PICC lines daily as used and change the dressings every week to prevent infection. She said when she observed Resident #70's IV dressing on 03/04/26 it read 02/22/26 and nursing staff talked about care of the dressing during the previous week. RN B said she administered IV antibiotics to Resident #70 on 03/03/26 and assessed the resident's dressing and she did know why she didn't change the dressing but the resident did not show any signs of infection (fever, swelling and redness at the site). In an interview on 03/06/26 at 11:17 AM, LVN J said IV dressing were changed every week to prevent infection. He said the new dressing must be signed, dated and initialed and documented in real time in the resident's chart. He said falsely documenting an IV dressing change placed residents at risk for missed treatments and infection, because once documented, the task was removed and only returned as a due task 1 week later. LVN J said on 03/01/26, he administered Resident #70s IV antibiotic and he did not remember any incidents that stopped the change of Resident #70's IV dressing or that Resident #70 refused the change of her IV dressing. LVN J reviewed Resident #70's EMR and said he documented the dressing change on 03/01/26 at 08:46 AM, but since the dressing was not changed, he must have just missed it. He said every time nursing staff rounded on a resident, or administered IV antibiotics they were expected to inspect the dressing and if necessary change it if it was over 1 week old. In an interview on 03/06/26 at 11:23 AM, NP Q said she was notified that Resident #70's IV line failed so she gave orders to have it replaced. She said the frequency by which nursing changed the resident's IV dressing was based on the facility policy but, dressings must be changed in order to prevent infection. NP Q said failure to change IV dressings as ordered placed resident at risk of infection or worsening of their current infections but Resident #70 had not displayed any signs of infection such as redness or swelling at the site. In an interview on 03/06/26 at 12:40 PM, Resident #70 said she had not experienced any signs and symptoms of infection such as swelling, pain, or redness at her IV site. She said on 03/04/26 her PICC line was changed, and she continued to receive her IV antibiotic. In an interview on 03/06/26 at 01:23 PM, the DON said IV dressings should be changed every week to prevent infection and the dressing must be dated when changed. She said failure to change the dressing placed residents at risk of infection that could go to their blood. The DON said inaccurate documentation of dressing changes could result missed treatment because it would remove the task from the MAR, but nurses were expected to assess the dressing and changed it if necessary when they provided care/administered IV antibiotics. Record review of RN B's Clinical Nursing Validation Review Checklist dated 08/14/25 revealed, she was assessed for:- Infection Control: Aseptic Dressing Change. The competency was met. Record review of the facility policy titled PICC or Midline Catheter Sterile Dressing Change with no revision date revealed, Purpose: A PICC (Peripherally Inserted Central Catheter) and a Midline catheter are special types of IV lines that can be used to give IV medicines or fluids. A dressing is needed to cover and protect your catheter site to help lower the risk of infection. Sterile technique will be used when doing the dressing change. How often does a dressing need to be changed?: Change the dressing every 7 days or as soon as possible if it is wet, soiled, loose, or open to the air or if physician states differently.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #7 and Resident #57) reviewed for infection control practices.1. ADON C failed to follow infection control practices when she cleaned Resident #7's trach with a towel that sat on the resident's chest on 03/04/26.2. RN B failed to follow infection control practices and did not use aseptic (sterile) technique when she suctioned Resident #7's Trach on 03/04/26 and 03/05/26.3. The facility failed to ensure a used single use push button lancet (a device with a hiding needle used to prick the skin for blood samples) was not left on Resident 57's nightstand on 03/04/2026. These failures could place residents at risk of bloodborne pathogens, cross contamination and respiratory infections.Findings include:1. Record review of Resident #7's, undated, face sheet revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included acute respiratory failure with hypoxia (lungs cannot adequately transfer oxygen to the blood), tracheostomy status (hole into windpipe to help with breathing), gastrostomy (hole into stomach for nutrition), and type 2 diabetes mellitus (body does not produce insulin or resists it).Record review of Resident #7's admission MDS assessment, dated 2/21/26, revealed a BIMS score of 15 out of 15, which indicated normal cognition. Resident #7 was dependent (helper does all the effort and resident does none of the effort) with all ADLs. According to the MDS, the resident was on oxygen continuously, received PRN suctioning, and received trach care.Record review of Resident #7's Care Plan, dated 2/20/26, revealed the resident had a tracheostomy r/t impaired breathing mechanics, and a history of cervical radiculopathy (nerve in neck is compressed/inflamed causing pain down arm/hand with numbness, tingling, weakness). The goal was for the resident to have clear and equal breath sounds bilaterally through the review date. The interventions included ensuring the trach ties were secured at all times, suctioning as necessary, and keeping the oxygen settings as ordered.Record review of Resident #7's Progress Note, from 2/27/26 by NP O, revealed .Tracheostomy in place and patent on trach collar. Continue routine tracheostomy care and suctioning as needed.Record review of Resident #7's Physician Orders revealed the following orders from MD A:- Aspiration (breathing in food or liquid) Precautions-Sit up 90 degrees, every shift. Ordered 2/19/26.- Change Disposable Inner Canula QD on 10pm-6am shift. Ordered 2/19/26.- Change Suction Canister as needed. Ordered 2/19/26.- Change Trach Mask Q Week, every night shift, every Sunday. Ordered 2/19/26.- Clean Inner Canula #6 Shiley (type of trach) QS & PRN. Ordered 2/20/26.- Clean Trach Collar, every night, every Sunday. Ordered 2/19/26.- Emergency Supplies at Bedside, every shift. Ordered 2/19/26.- O2 @ 4L via Trach to maintain sats above 92%, every shift for hypoxia (not enough oxygen in blood). Ordered 3/5/26.- O2 @ 6L via Trach to maintain sats above 92%, every shift for hypoxia. Ordered 2/20/26.- Suction Trach as needed for airway clearance. Ordered 2/19/26.- Trach Care HS Shift & PRN, as needed for soiled. Ordered 2/19/26.- Trach Care HS Shift & PRN, every night shift. Ordered 2/19/26.Record review of Resident #7's Nurse's Note, from 3/4/26 from LVN E, revealed the resident was alert and oriented to person, place, and time and had no confusion. His lungs were clear and he had no cough. Resident #7 had a trach collar and no shortness of breath.An observation on 03/04/26 at 10:49 AM revealed, Resident #7 lying in bed, well-groomed and in no immediate distress, his breathing was unlabored and rate was normal. The resident had a trach collar (a device worn around the neck to secure a tracheostomy tube in place, preventing dislodgement), his oxygen concentrator delivered O2 at 4 L/min and the oxygen mask was not over his trach. The state surveyor alerted ADON C, who entered the room, cleaned Resident #7's trach collar with a non-sterile towel that sat on his chest and placed the oxygen mask over Resident #7's trach collar. An observation on 03/04/26 at 10:58 AM revealed, RN B entered into Resident #7's room to suction the residents trach. She gathered her supplies, and donned sterile gloves. With her sterile gloves on, she opened drawers and gathered nonsterile supplies, unsheathed the sterile suction canula from its wrapper and then re-sheathed it while she adjusted the resident. RN B then unsheathed the suction canula, turned on the machine and suctioned the resident after telling him what she was going to do and instructing him to alert her if he had any discomfort. While unsheathing and re-sheathing the suction canula, RN B touched the canula with her contaminated gloves. Resident #7 displayed no signs of respiratory distress through the process.In an observation on 3/5/26 at 1:26 PM, revealed Resident #7 was sitting up in bed with a moderate amount of thick, yellow, mucus coming out of his trach. There was a suction machine and Ambu bag (used to deliver breaths during CPR) at the bedside. RN B washed her hands, donned a gown and then gloves. RN B applied a pulse oximeter (measures heart rate and percentage of oxygen in blood) to the resident's finger and left it there during the whole treatment. Resident #7's pulse oxygen stayed in the upper 90s, which was normal. She then wiped away the mucus with a tissue, took off her dirty gloves and applied clean gloves. She then removed the dirty gauze that was around the trach, removed her dirty gloves, washed her hands, and applied sterile gloves. RN B then prepared the bedside table with supplies. She opened a sterile trach care kit, she opened a new inner canula and then opened three packages of sterile gauze without touching them and attempted to have them land on the sterile field, but one of them landed halfway on the sterile field and halfway off. She also poured sterile water into a cup and put it on the bedside table. She applied a sterile drape over the resident's chest and then opened the suction catheter from the sterile package and attached it to the suction tubing, leaving the tip of the suction in the sterile package. She removed her dirty gloves and then applied the sterile gloves from the trach kit. RN B picked up the suction catheter and removed it from the sterile package and turned on the suction machine with the back of her sterile hand. Then she removed the resident's inner canula and placed it on the drape on his chest. The nurse suctioned the resident's trach three times as she was pulling the suction catheter out. She waited a few seconds between each suction to give the resident time to re-oxygenate. When RN B was done suctioning, she turned off the suction machine with her sterile hand and then balled up the wrapper from the suction catheter, along with the dirty suction catheter, and threw it away. She did this with her sterile gloves on. The nurse then picked up a sterile inner canula with the same gloves she had on and inserted it into Resident #7's trach. Then she picked up sterile gauze and wiped around the outside of the resident's trach to clean up the mucus, with the same dirty gloves. RN B finished care as the State Surveyor stepped out.In an interview on 3/5/26 at 1:46 PM, ADON B said in-services on trachs were given annually, every 6mths, and they used the dummy as a simulation for new hires. She said they had just had in-services on trachs and trach care. The ADON said they did not get trach resident's often, but they had had about 5 residents in the last 4-5 months. She said all the nurses were trained on trachs. The ADON said if the sterile technique was broken during trach care/trach suctioning there would be a risk for infection.In an interview on 3/5/26 at 2:00 PM, RN B said she was so nervous she was unsure of what mistakes she had made. She said a break in the sterile technique could cause an infection. She said this was the first time the resident had yellow mucus and she was going to call the provider and let them know about it.In an interview on 3/6/26 at 11:41 AM, the DON said sterility during suctioning was very important. She said it was important to have all the supplies available and opened before starting, and it had to be done using the sterile technique. The DON said one hand would remain sterile while the other remained clean, when suctioning. She said then once suctioning was done, the sterile hand would pick up the inner canula and insert it into the trach. The DON said if the sterile hand touched other things and then inserted the inner canula, it would introduce germs into the trach and could cause an infection.Record review of the facility's policy and procedures on Suctioning the Lower Airway (Endotracheal [ET] or Tracheostomy Tube) (revised October 2010) read in part: The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Assemble the equipment and supplies as needed.Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).The following equipment and supplies will be necessary when performing this procedure: Sterile suction catheter kit; Sterile drape; Sterile cup; Sterile gloves; #10 to #16 French [size] catheter; Sterile gauze; Sterile saline or sterile water.Perform hand antisepsis. Put on gloves. Turn on suction unit and adjust to appropriate negative pressure. Remove gloves. Open suction catheter kit. Place sterile drape across the resident's chest. Remove sterile cup, touching only the outside. Fill cup with sterile saline or sterile water. Apply sterile gloves. Recommend: The dominant hand will remain sterile. Holding the catheter in dominant hand and the tubing in the non-dominant hand, connect the catheter to the tubing. Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit). Remove oxygen or humidity delivery device using non-dominant hand. Instruct the resident to inhale. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME] [base of windpipe where it splits into left and right lung). Pull back 1 to 2 cm. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than 10 seconds. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions. Rinse catheter and tubing with sterile saline or sterile water until clear.Limit suction passes to a maximum of three.Record review of the facility's policy and procedure on Tracheostomy Care (revised August 2013) read in part: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. Open tracheostomy cleaning kit. Set up supplies on sterile field. Maintaining sterile field.Open four gauze pads and saturate with hydrogen peroxide. Open two gauze pads and saturate with antiseptic solution. Open two gauze pads and saturate with sterile saline. Open two gauze pads; keep them dry. Put on sterile gloves. Secure the outer neck plate with non-dominate gloved hand. Unlock the inner cannula with gloved dominate hand. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Remove and discard gloves into appropriate receptacle. Wash hands and put on fresh gloves. Replace the cannula carefully and lock in place.Apply clean gloves. Clean the stoma with two peroxide-soaked gauze pads (using a single sweep for each side). Rinse the stoma with saline-soaked gauze pads (using a single sweep for each side). Wipe with dry gauze (using a single sweep for each side). Apply a fenestrated gauze pad around the insertion site.Record review of the facility's policy titled Blood-Sampling- Capillary (Finger Sticks revised 09/2014 revealed, Purpose: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees . Steps in the Procedure: 5. Wipe the area to be lanced with an alcohol pad/wipe. 6. Obtain the blood sample, following the manufacturer's instructions for the device. 7. Discard lancet and platform into the sharps container . Record review of the facility's policy and procedures on Infection Prevention and Control Program (revised August 2016) read in part: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures.prevention of infection .The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).Important facets of infection prevention include:.educating staff and ensuring that they adhere to proper techniques and procedures.

Based on observations, interview and record review the facility failed to ensure the medication error rate was not 5% or greater. The facility had a medication error rate of 6.0%, based on two errors out of 29 opportunities, which involved 2 of 4 residents (Residents #3 and #64) and 2 of 2 (RN B and MA C) staff observed during medication administration reviewed for medication errors. -The facility's staff failed to administer scheduled medications to Residents #3 and #64.-This failure could place residents at risk of receiving less than optimal results from their medication regimen.Findings included:. Record review of Resident #64's Physician Orders, dated 03/05/2026, revealed active orders of the following medications:- Amlodipine oral (by mouth) tablet 10 mg. Give 1 tablet by mouth one time a day for High blood pressure.- Aspirin low dose oral tablet 81 mg. Give 1 tablet by mouth one time a day related to paroxysmal atrial fibrillation (irregular heart rhythm).- Buspirone tablet 5 mg. Give 2 tablet by mouth three times a day for anxiety (the body's response to stress, characterized by feelings of fear, dread, apprehension, and uneasiness).- Cholecalciferol oral tablet 25 mcg. Give 1 tablet by mouth every 12 hours for vitamin D deficiency (when the body does not have enough vitamin D).- Docusate oral capsule 100 mg. Give 2 capsules by mouth in the morning for constipation.- Finasteride oral tablet 5 mg. Give 1 tablet by mouth one time a day for BPH (noncancerous enlargement of the prostate).- Losartan oral tablet 25 mg. Give 1 tablet by mouth one time a day for high blood pressure.- Methocarbamol oral tablet 500 mg. Give 1 tablet by mouth three times a day for spasm.- Metoprolol ER oral tablet Extended Release 25 mg. Give 1 tablet by mouth one time a day for CAD (a heart disease, occurring when plaque builds up inside the arteries that supply blood to the heart, causing them to narrow and harden).- Omega-3 oral Capsule. Give 3 capsules by mouth one time a day for Heart health.- Ondansetron tablet 4 mg. Give 1 tablet by mouth one time a day for nausea and vomiting.- Oxycodone oral tablet 5 mg. Give 1 tablet by mouth every 4 hours for severe pain.- Sertraline oral tablet 50 mg. Give 1 tablet by mouth one time a day for depression.- Vitamin C oral tablet 500 mg. Give 1 tablet by mouth one time a day for vitamin C deficiency.- Allopurinol oral tablet 300 mg. Give 1 tablet by mouth one time a day for gout (a type of inflammatory arthritis that causes pain and swelling in your joints).During an observation on 03/05/2026 at 7:57 a.m., revealed RN B prepared and administered the following medications to Resident #64: Aspirin tablet 81 mg, cholecalciferol tablet 25 mcg, finasteride tablet 5 mg, methocarbamol tablet 500 mg, ondansetron tablet 4 mg, Fish Oil (brand name for Omega-3) 3 capsules, vitamin C tablet 500 mg, buspirone tablet 10 mg, sertraline tablet 50 mg, Docusate 100 mg 2 capsules, oxycodone tablet 5 mg, metoprolol tablet 25 mg, amlodipine tablet 10 mg, losartan tablet 25 mg. RN B did not administer allopurinol tablet 300 mg. RN B concluded administering Resident #64's medications and started to prepare medications for another resident. Further observation revealed allopurinol was available in the medication cart.During an interview on 03/05/2026 at 11:45 a.m., RN B stated she gave all the scheduled medications to Resident #64 including allopurinol.2. Record review of Resident #3's Physician Orders, dated 03/05/2026, revealed active orders of the following medications:- Baclofen oral tablet 10 mg. Give 1 tablet by mouth two times a day for spasm.- Ergocalciferol oral capsule 1.25 mg. Give 1 capsule by mouth one time a day, every Thursday for supplement.- Lacosamide oral tablet 100 mg. Give 1 tablet by mouth two times a day for seizure (a sudden, temporary burst of uncontrolled electrical activity in the brain that disrupts normal function).- Metformin ER tablet extended release 500 mg Give 1 tablet by mouth one time a day for Diabetes.- Metoprolol oral tablet extended release 25 mg. Give 1 tablet by mouth one time a day for high blood pressure.- Rifaximin oral tablet 550 mg. Give 1 tablet by mouth two times a day for liver diseases.- Rivaroxaban oral tablet 2.5 mg. Give 1 tablet by mouth every 12 hours for peripheral artery disease (condition where plaque builds up in the arteries that carry blood to your legs or arms, causing them to narrow).- Sodium chloride oral tablet 1 gm. Give 2 tablet by mouth two times a day for low sodium levels.- Urea oral packet 15 gm. Give 1 packet by mouth two times a day for low sodium levels.- Sulfasalazine oral tablet 500 mg. Give 1 tablet by mouth two times a day for Rheumatoid arthritis (a chronic disease where the immune system mistakenly attacks the lining of the joints, causing painful inflammation, stiffness, and swelling).During an observation on 03/05/2026 9:25 a.m., revealed MA C prepared and administered the following medications to Resident #3:Metoprolol tablet 25 mg, urea oral packet 15 gm, metformin tablet 500 mg, sodium chloride tablet 1 gm, baclofen tablet 10 mg, ergocalciferol tablet 1.25 mg, rivaroxaban tablet 2.5 mg, rifaximin tablet 550 mg, lacosamide tablet 100 mg. MA C did not administer Sulfasalazine oral tablet 500 mg. MA C concluded administering Resident #3's medications and started to prepare medications for another resident. Further observation revealed sulfasalazine was available in the medication cart.During an interview on 03/05/2026 at 11:00 a.m., MA C stated she gave all the scheduled medications to Resident #3, including sulfasalazine.During an interview on 03/05/2026 at 12:55 p.m., the DON stated she expected all nurses and MAs to administer all scheduled medications. She stated staff should have double checked residents' MARs and medication containers before they administered medications and made sure, they did not miss any medication. She stated if staff did not administer scheduled medications, residents would suffer from delay in their treatment plans. The DON stated she performed random audits every day while staff passed medications. She stated she did not perform an audit on the day of the observation due to state survey.During an interview on 03/06/2026 at 11:30 a.m., the NP stated she expected all nurses and MAs to notify her when they missed any medication administration. She stated Residents #3 and #64, who missed one dose of their medications, could experience mild pain and required to adjust their medication scheduled times on the day when both missed their medications.Record review of the facility's Administering Medications Policy, dated April 2019, revealed, .2.The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.10.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 22 Residents (Resident #65) reviewed for food prepared in a form designed to meet individual needs. The facility failed to ensure Resident #65's dietary orders and preference of a mechanical soft diet when were followed when the resident was served dry lightly toasted toast for breakfast and boiled potatoes with the skin for lunch on 03/05/2026. This failure could place residents at risk of difficulty chewing, choking and weight loss. Findings include: Record review of Resident #65's face sheet, dated 03/05/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #65 had diagnoses which included: paralysis and weakness on the right dominant side following a stoke ( brain damage caused by a blockage in a blood vessel do to lack of oxygen and nutrients), Parkinsonism (group of neurological disorders causing motor symptoms similar to Parkinson's disease), high blood pressure, high cholesterol and speech disorders affecting articulation (formation of clear and distinct sounds in speech). Record review of Resident #65's admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 11 out of 15. Resident #65 required supervision or touching assistance with eating. Record review of Resident #65's, undated, Care Plan revealed Focus: The resident has potential nutritional problem r/t No Added Salt (NAS) diet, Mechanical Soft texture, Regular Liquids consistency; Interventions: Monitor/document/report PRN any s/sx of dysphagia (difficulty swallowing): Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Provide, serve diet as ordered. Monitor intake and record Q meal. Record review of Resident #65's Order Summary Report, dated 03/05/26, revealed No Added Salt (NAS) diet Mechanical Soft texture, Regular Liquids consistency, please give orange juice and fruit punch with meals. Started 01/30/26. Record review of Resident #65's Progress Notes revealed, -01/30/26 at 01:15 PM signed by RN B, patient downgraded to mechanical soft since patient and family member concerned about patient having difficulty in swallowing regular food from before while being in hospital. An observation on 03/05/26 at 08:30 AM revealed Resident #65 sat in his room eating breakfast. His plate had scrambled eggs, chopped breakfast sausage covered in white gravy and 2 slices of toast. The toast was full, uncut, dry and lightly toasted. Resident #65's meal ticket read diet: mechanical soft, regular liquids, no added salt. There were no notes, alerts, standing orders or dislikes documented on the meal ticket. In an interview on 03/05/26 at 01:04 PM, the Dietary Manager said a resident's dietary orders were entered into the EMR which was integrated into the kitchen system that provided instructions on how to prepare meals for each diet type. She said a mechanical soft diet was typically ordered due to swallowing issues, chewing issues or a residents preference. She said the cooks assembled the meals based on the information printed by the facility system on the individual resident's meal tickets and those with mechanical soft diets received chopped meats and mashed potatoes without skins for ease of chewing for today's lunch. She said the kitchen systems still allowed those on mechanical soft diets to eat bread like dinner rolls and lightly toast since they could not eat anything hard. The Dietary Manager said failure to provide residents with food that met their orders, needs and preference placed residents at risk for difficulty chewing and possibly choking. An observation and interview on 03/05/26 at 01:17 PM revealed Resident #65 sitting in his wheelchair eating lunch. His plate contained a dinner roll, chopped meat, boiled/ baked potato and green leafy steamed vegetables. The potatoes had skin covering majority of the surface and was un-mashed. The potatoes and the dinner roll were left untouched. Resident #65 said his mechanical soft diet was a preference, he did not have swallowing issues, but he found a regular diet tough to chew. He said it was tough to: chew the skins on potatoes, bread such as a dinner roll and the toast was even harder to chew. Resident #65 said when his meals were not soft, they did not prevent him from eating but just made it hard to eat. He said he had not suffered from any weight loss. An observation on 03/05/26 at 02:00 PM of the requested mechanical soft test tray revealed, chopped meat, mashed potatoes with no skin, steamed vegetables and a dinner roll. Record review of the facility's policy titled Alternate Food Choices and Substitutions Policy Number: 02.004and Honoring Preferences approved 10/01/18 revealed, Policy: The facility believes that adequate nutrition is essential to each resident's well-being and good health. An alternate entree and vegetable will be offered at each meal. The facility also supports resident choice and allowing residents to choose foods by honoring their food preferences. Other substitutions will also be available in the event a resident does not choose the main meal or the alternate. 2. The Nutrition & Foodservice Manager or designee will obtain the resident's food preferences upon admission and record preferences in the tray card system.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to post the Daily Staffing Hours in a location visible to all by posting it on the wall on the left side of the building between the 100 and 200 Hall from 03/04/26 to 03/06/26.- The facility failed to include the resident census and the total number and actual hours worked by direct care per shift on the Nursing Staffing information from 03/04/26 to 03/06/26. These failures could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 03/04/26 at 8:24 AM revealed, the Daily Staffing Hours was posted on the left side of the hall in a clear placard by the DON's office between the 100 and 200 halls. The date reflected 03/03/26, and included the number of staff, number of hours and total number of hours worked per position (RN, LVN, CNA and MA). It did not include the resident census or the shifts worked by the direct care staff. An observation on 03/05/26 at 9:00 AM revealed, the Daily Staffing Hours was posted on the left side of the hall in a clear placard by the DON's office between the 100 and 200 halls. The date reflected 03/05/26, and included the number of staff, number of hours and total number of hours worked per position (RN, LVN, CNA and CMA). It did not include the resident census or the shifts worked by the direct care staff. An observation on 03/06/26 at 8:34 AM revealed, the Daily Staffing Hours was posted on the left side of the hall in a clear placard by the DON's office between the 100 and 200 halls. The date reflected 03/06/26, and included the number of staff, number of hours and total number of hours worked per position (RN, LVN, CNA and CMA). It did not include the resident census or the shifts worked by the direct care staff. In an interview on 03/04/26 at 12:17 PM, the Administrator said the receptionist filled out the Daily Staffing Hours posting using the provided template every morning. In an interview on 03/04/26 at 12:39 PM, the Administrator said after reviewing the TAC the expectation of the nurse staffing posting was that it included: the facility name, date, census, and the total number of hours scheduled and worked for each staff type per shift and its purpose was to notify all in the building the resident to staff ratio and it must be posted in a common area. She said the posting was located by the DON's office and visitors that went exclusively to the 100, 300 and 400 halls would not see the posting due to its location. The Administrator said failure to include the different shifts, the resident census, and to not post it in a prominent location would leave people unaware of the staff to resident ratio across the different shifts In an interview on 03/06/26 at 03:24 PM, the Administrator said the facility did not have a policy addressing the required staffing policy. She said they used the regulations as listed in the Texas Administrative Code (TAC).

Based on observation, record reviews and interviews, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area to each resident's bedside;abd /toilet and bathing facilities for 1 of 5 residents (Resident #1) reviewed for call lights.The facility failed to ensure Resident #1's call light was within reach on 02/06/2026, while he was lying bed.This failure could place residents at risk of not receiving immediate assistance when needed. Findings included: Record review of Resident #1's Face Sheet revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting, abnormality of gait and mobility, difficulty in walking, and lack of coordination.Record review of Resident #1's most recent Quarterly MDS (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status, used in nursing homes) dated 11/10/2025 revealed, BIMS (a standardized, mandatory 0-15 point cognitive assessment tool used in long-term care settings to measure mental acuity in residents) of 4. He used a wheelchair for mobility. He required partial/moderate assistance from staff with personal hygiene and upper body dressing. He was always incontinent with bowel and bladder.Record review of Resident #1's Care Plan dated 02/05/2025, included Problem: The resident was at risk for falls related to Diabetes, Neuropathy (nerve damage), and had recurrent falls. Goal: The resident will be free of falls. Interventions included: Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance.During an observation and interview on 02/06/26 at 12:40 p.m., revealed, Resident #1 lying in bed, his call light was observed between the bed rail mattress, and out of Resident #1's reach. Resident #1 stated he wanted to call staff to request water, but he could not reach his call light. Resident #1 stated he usually could reach his call light but not this time. During an interview on 02/06/26 at 1:04 p.m., CNA A stated call lights should be within residents' reach. She stated Resident #1 needed the call light to request assistance when needed. CNA A stated she checked the call lights after she provided care to the residents. CNA A stated if call lights were not within residents' reach, they might fall. During an interview on 02/06/26 at 1:12 p.m., the DON stated she expected all staff to check Residents call lights when they went into residents' room. The DON stated if call lights were not within residents' reach, staff should have picked them up and placed them by the residents. The DON stated staff should have used clips to ensure call lights stayed attached to Residents beds and were within their reach. The DON stated she expected staff to check call lights before they left residents rooms. She stated if the call lights were not within residents' reach, they would not be able to ask for help and that might jeopardize their safety.During an interview on 02/06/26 at 1:23 p.m., LVN A stated call lights should be within reach of residents. She stated nurses and CNAs should have noticed Resident #1's call light was out of his reach and clipped it to his bed.Record review of the facility's Call Lights Policy dated August 2021, revealed, Staff to place the call light within the reach of the resident when leaving the room.

Based on observations, interviews, and record reviews, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 6 resident (Resident #1) reviewed for pressure ulcers. -The facility failed prevent development a pressure ulcer which was not identified or treated for Resident #1. This failure placed residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain and infection. Findings Include: Record review of Resident #1's Face Sheet dated 6/13/2024 revealed, an [AGE] year-old male who admitted to the facility originally on 3/17/2021 and most recently on 2/29/2024 with the following diagnoses which included: contracture unspecified joint, hemiplegia and hemiparesis (paralysis and partial weakness) following cerebral infarction (stroke) affecting left non dominate side, unspecified dementia, unspecified mood (affective) disorder, muscle wasting and atrophy. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADLs, total dependence with most functional abilities including shower/bathe self, upper body dressing. Substantial/maximal assistance (helper does more than half the effort) assistance with personal hygiene (includes washing and drying hands). Active Diagnosis included: Hemiplegia or Hemiparesis. Skin Conditions included: Resident was at risk for pressure ulcers/injuries. Other ulcers, Wounds and Skin Problems: Resident had Skin tears. Record review of Resident #1's Care Plan (date initiated 5/2/2022) revealed, Focus: [Resident #1] has an ADL self-care performance deficient r/t Dementia. Goal - [Resident #1] will maintain current level of function through the review date. Interventions - .Provide skin care every shift and PRN to keep clean and prevent skin breakdown (date initiated 10/11/2023). Geri-sleeve bilateral forearms (date initiated 1/30/2024). Contractures: [Resident #1] has contractures of the left hand. Provide skin care to keep clean and prevent skin breakdown (date initiated 5/17/2022). Focus: [Resident #1 is risk for impaired skin integrity r/t immobility .resident had tendency to scratch self . Goal: [Resident #1 skin will remain intact through next review date (target date 6/5/2024). Interventions: Evaluate skin for areas of .redness. Keep skin clean and well lubricated. Nurse to check the skin after bathing for any skin issues . Perform objective pressure ulcer risk tool such as Braden/Norton Scale (date initiated 8/6/2021). Record review of Resident #1's order summary report dated 6/12/2024 revealed geri-sleeves bilateral forearms every shift for wound care (order and starts date 4/23/24). Record review of Resident #1 weekly skin assessment dated [DATE] revealed, no documentation of a wound, redness or skin tear between the index finger and thumb on his left hand. Record review of Resident #1's TAR dated 6/1/24 - 6/10/2024 revealed it was charted by RN A and LVN B the geri-sleeve were in place every shift for wound care (start date 4/23/2024). Record review of Resident #1's shower sheets dated 6/7/2024 and 6/10/2024 revealed no skin issues were documented by CNA A. Record review of Resident #1's Nursing Notes dated 6/11/2024 at 12:02 a.m. revealed, resident [Resident #1] left the facility to the hospital at 10:05 p.m. (6/10/2024). [Resident #1] had no new skin issues at the time of the transfer. Record review of EMS Run Report for Resident #1 dated 6/10/2024 revealed the following (nursing facility to hospital emergency room ): Arrived on scene: 6/10/2024 at 9:51 p.m. Patient Contact: 6/10/2024 at 9:52 p.m. Transport Began: 6/10/2024 at 10:21 p.m. Arrival at Destination: 6/10/2024 at 10:38 p.m. .Patient [Resident #1] was found at 21:52:44 (9:52 p.m.) in emergent (yellow) condition. The patient is a [AGE] year-old adult male. The patient transportation for nausea and vomiting, coughing not available at origin. A stretcher was required due to the patients' monitoring requirement - oxygen administration (oxygen dependent, severe weakness in all extremities, and poor truck control). Patient was moved to the stretcher by two-man drawsheet .and secured inside .Transport began at 22:21:11 (10:21 p.m.) .and lasted 17 minutes .Forearm - left paralysis, Arm - whole arm and hand- left deformity .arrived at [hospital] at 22:38:49 (10:38 p.m). Record review of Resident #1's hospital emergency room admitted d 6/10/2024. Principle problem: Pneumonia or right lung due to infectious organism, unspecified part of lung. Record review of a photograph dated 6/10/24 at 12:04 p.m. revealed Resident #1's left hand with geri-sleeve. There was dark brownish dried substance along the edge of the geri-sleeve between the index finger and thumb. The inside of thumb appeared to have brown dried substance. The second photograph revealed attending ER Physician A holding Resident #1's hand and displayed the wound bed between the index finger and thumb with the geri-sleeve off. The wound bed was red and pink in color an appeared moist. The edge of the wound bed closest to the thumb was brown in color. The edge of the wound bed closest to the index finger was red. There was a blister in the center of the wound bed. The around the peri wound (area around the wound bed) appears light red, pink and light brown in color. Record review of Resident #1's hospital emergency room wound photograph dated 6/11/2024 at 1:01 a.m. reflected the wound bed was red and pink in color an appeared moist. The edge of the wound bed closest to the thumb was brown in color. The edge of the wound bed closest to the index finger was red. There was a blister in the center of the wound bed. The around the peri wound (area around the wound bed) appears light red, pink and light brown in color. Record review of Resident #1's hospital emergency wound assessment dated [DATE] at 6:00 a.m. revealed the following: First Assessment Date/First Assessment Time: 06/11/24 06:00 Present on Original Admission: Yes Primary Wound Type: Other (comment) Orientation: Left; Posterior Location: Finger D1, thumb Description (Comments): in between thumb and 2nd digit web area Wound Care Physical Therapy Diagnosis: Impaired Integumentary Integrity Associated with Partial-Thickness Skin Involvement and Scar Formation Pt referred to PT wound care to the L hand. Mobility/Transfer: total assistance Needs additional assist to position and open hand during wound care . 6/12/2024 at 1:26 p.m. - Nonstaged wound description - Partial thickness. Wound base appearance - early/partial granulation; red; pink; slough (dead tissue in wound) Wound bed granulation (new connective tissue) % - 80% Wound bed slough (dead tissue in wound) % - 10% Exposed structures - Muscle; Muscle Necrosis (death of body tissue) Peri-wound assessment - pink; white; macerated (soften or become softened by soaking in a liquid) Margins - attached edges Wound length - 4 cm Wound width - .6 cm Wound depth - .3 cm Wound measured as a cluster? - Yes Wound Surface area - 2.4 cm^2 Wound Volume - .72 cm ^2 Drainage: small Drainage odor: none Drainage Description: Serosanguineous (refers to fluids that contain or relate to both blood and the liquid part of blood (serum) Wound cleanse: irrigation; cleansed; peri wound care; normal saline. Primary Dressing - small piece of foam secured with tape. Patient seen for PT wound care eval and treatment to the Left hand wound per above. Left hand with flex contractures from old stroke and wound is macerated. Patient will be seen for PT wound care 3 times a week., Nursing to change/reinforce dressings as needed or when soiled. Record review of video of Resident #1 date and time stamped (6/10/2024 at 9:06 a.m.) revealed CNA A prepared to give Resident #1 a bed bath. She removed socks from a drawer and had a container with a pump in the other hand. CNA did not take a new geri-sleeve out of the drawer to change out the one that Resident #1 had on. Interview on 6/12/2024 at 12:55 p.m. with CNA A said Resident #1 wore protective geri-sleeve on his arms because he would scratch himself. She said he always wore the sleeves except when he had a bed bath. She said she gave Resident #1 a bed bath on 6/10/2024 at approximately 9:00 a.m. She said she removed Resident #1's left geri-sleeve and cleaned his arms. She said she checked for bruises or skin tears. She said he had discoloration on the top of his hand that had been there previously. She said she was supposed to report if Resident #1 had any new skin tears or bruises. She said, I did not recall seeing anything on his left hand after the bed bath. She said, the arm sleeves are washed and reused. Interview on 6/12/2024 at 1:12 with the WC A said Resident #1 did not have any skin issues or wound when he started wearing the geri-sleeves. She said he was ordered to have weekly skin assessments. She said she last completed Resident #1's skin assessment on 6/6/2024 and he had no issues. She said she saw Resident #1 in bed on 6/10/2024 during the day but did not see anything out of the ordinary. She said she stood at the room door and looked in and saw that the resident had on the geri-sleeves but did not walk over to him. Observation and attempted interview on 6/12/2024 at 2:07 p.m. of Resident #1 at the hospital revealed Resident was in the hospital bed. Resident #1 was asked if staff had taken off his protective geri-sleeve when he received a bed bath. Resident #1 did not respond. Resident was asked if he was in pain, and he did not respond. Resident #1 had a gauze bandage wrapped around his left hand between the index finger and the thumb. He held his left hand against his chest, with the thumb closest to his chest. Interview on 6/12/2024 at 3:34 p.m. via phone with CNA A said she did not see blood, skin tears or scabs on Resident #1's left contracted hand or any dried substance on the geri-sleeve. She said she was not trained or informed by a nurse on when to take the geri-sleeves off other than when she gave Resident #1 a bed bath. CNA A said she placed the same sleeves back on Resident #1 on the bed bath she gave him on 6/10/2024. She said she did not specifically look at the webbing between the index finger and the thumb. She was not able to explain how she removed the arm sleeve, washed the arm but and did not see the area between the index finger and the thumb. Interview on 6/13/2024 at 8:38 p.m. with NP A said he expected the staff to ensure the geri-sleeves were in place for Resident #1. He said the facility would have decided when the sleeves should have been taken off. NP A said the order was to ensure the sleeves were always in place, because Resident #1 scratched himself. He said when Resident #1 was showered was acceptable. He said the facility had not called him to clarify the order for the geri-sleeves. Interview on 6/13/2024 at 9:04 a.m. with CNA B said she could not remember when she last provided Resident #1 with a bed bath. She said in the past she had to remove the arm sleeves when Resident #1 was given a bed bath. She said he kept the sleeves on to prevent him from scratching himself. She said she was trained by RN A to keep the sleeves clean and dry. Interview on 6/13/2024 at 9:29 a.m. with RN A said it was her understanding that she was responsible to ensure the geri-sleeves were on. RN A said Resident #1 wore the protective geri-sleeves to prevent skin tears, because he would scratch himself. She said the Nurses and CNA's were responsible and needed to change the geri-sleeves of soiled or on shower days. RN A said she documented daily on Resident #1's TAR that the geri-sleeves were in place. She said, she made sure they were in place, and she eyeballed them. She said eyeballed meant she visibly looked to see if the sleeves were on. She said she did not physically touch the sleeves. RN A said on 6/10/2024, she worked 6:00 a.m. - 2:00 pm. She said she did not check Resident #1's skin or look under the sleeves. RN A said LVN B worked after her on 6/10/2024. Interview on 6/13/2024 at 9:56 a.m. with WC A said Resident #1 was checked from head to toe on his last weekly skin assessment (6/6/2024). She said she checked the arms and removed the sleeves slow and gentle and looked for pressure points as she pointed to the elbows. She said the sleeves should be on at all times except when they were soiled or when he received a bed bath. She said she made sure the sleeves were pulled up and were not creased so not to cause a potential injury. WC A said the nurses monitored and made sure the sleeves were on. She said she saw his contracted left hand, but she said she did not particularly look at that part between the thumb and index finger, because it was very difficult to look at. She said he always held the contracted left hand, which was paralyzed, close to his chest. Interview on 6/13/2024 at 10:29 a.m. LVN A said she sent Resident #1 to the hospital on 6/10/2024 at the request of Resident #1's family member. She said before sending him out she performed mouth care and a brief change. She said she did not examine his arms or geri-sleeves. LVN A said she ensured the geri-sleeves were in place, but she did not inspect his skin for new injuries or skin tears. LVN A said she checked his blood pressure with the left wrist and he did not open the left contracted hand. She said she did not observe the area between the index finger and the thumb. She said she did not change Resident #1's sleeve during her 2:00 p.m. -10:00 p.m. shift. She said the CNA's normally changed the geri-sleeve if Resident #1 needed it. Interview on 6/13/2024 at 10:42 a.m. the DON said based on Resident #1's order for the geri-sleeve, she expected the nurses to make sure the sleeves were in place and to check if there was any negative affects from pressure. She said it should be checked like a hand splint for example. The DON said she ensured the sleeves were monitored for Resident #1 by reviewing the TAR was completed daily. The DON said she had not trained the nurses on geri-sleeves but said it was a nursing standard of practice and they should have known to check the skin. She said she expected then nurses to check the placement and to look under the sleeve. Interview on 6/13/2024 at 11:58 a.m. with CNA C said she assisted with Resident #1's brief change on 6/10/2024 before he was transferred to the hospital. She said she checked and made sure the geri-sleeve was on but did not check if the sleeve had blood, dried blood or if there was an injury. She said she did not look or inspect between his index finger and thumb and did not check his skin. She said she was trained to report new injuries if observed during a bath or if there was a changed needed because the sleeves were soiled. Interview on 6/13/2024 at 2:00 p.m. with WC B said she performed wound care on Resident #1's left hand on 6/12/2024 at the hospital. WC B said the injury was caused by pressure and was present prior to Resident #1's admission to the ER. She said they do not stage in this area but there was partial thickness (damage to the first two layers of skin). Interview on 6/13/2024 at 2:12 p.m. with the Attending ER Physician said Resident #1 had a contracted left hand on 6/10/2024. She said she remembered skin break down between the index finger and thumb. She said it was red, pink and had a small amount of drainage. The Attending ER Physician said the wound was present when Resident #1 arrived at the ER. She said Resident #1 had blood that soaked through the geri-sleeve and dried between the index finger and thumb. Interview on 6/14/2024 at 9:35 a.m. with RN B said he worked the night of 6/10/2024 in the hospital emergency room . He said Resident #1 came via ambulance. RN B said Resident #1 had on an elastic arm sleeve on his left arm and he placed an IV in the same arm. He said Resident #1 was nonverbal. RN B said the webbing between the index finger and the thumb was not intact. He said the top two layers of Resident 1's skin was gone and there was pink and red flesh exposed. He said he took photos of the left-hand injury within approximately the first hour of admission. He said the Attending ER Physician recommended photographs of the injury to have proof the resident arrived with the wound. He said he could not recall if Resident #1 exhibited pain. Interview on 6/14/2024 at 11:39 a.m. with the Administrator said based on the order she expected nurses to ensure the geri-sleeves were in place and assess the skin once a shift. She said she expected cna's to report any new skin issues to the nurses when Resident #1's skin was observed during bed baths and ensure the geri-sleeves were on. She said WC A was expected to do a head-to-toe assessment. She said if Resident #1 was reluctant to a complete head to toe assessment, that should have included his arms and hands, then the WC A should have let Resident #1 calm down, try again later and maybe try with another staff to assist to address the skin that was not seen. She said she and DON completed daily rounds to ensure staff were meeting the needs of the residents. Record review of facility policy System pathway #1 - Skin and Wound Management revealed the following in part: Each resident receives the care and services necessary to retain or regain optimal kin integrity to the extent possible. Each resident skin is assessed to determine his or her risk for the skin integrity being compromised or the presence of wounds and or pressure injuries. A plan of care should be developed and implemented based on the skin review/checks. If the skin is compromised, the interdisciplinary team notifies the physician for any orders and those appropriate measure and additional interventions are put in place to minimize further compromising of skin and to aid in the healing to extent possible. Responsible Disciplines: Licensed Nursing, CNA's, Therapists Record review of facility job description Charge Nurse dated 4/1/2019 revealed the following in part: To ensure that each patient's attains or maintains the highest possible level of functioning by providing quality nursing care and by working with the interdisciplinary team to ensure a holistic approach to patient care. 1. Follow established standards of nursing practices . Record review of facility job description Treatment Nurse dated 4/1/2019 revealed the following in part: The primary purpose of this position is to provide oversight of the primary skin care provided to residents . 1. Identify, manage, and treat specific skin conditions and primary and secondary lesions, such as skin abrasions, . pressure injuries/ulcers . 2. Perform skin assessments using techniques including observation, inspection . 10.reporting skin concerns . Record review of facility job description Certified Nursing Assistant dated 4/1/2019 revealed the following in part: To support each patients' physical needs by providing top quality care in accordance with community policies and procedures. Record review of facility policy Assistive Devices and Equipment (date revised January 2020), revealed the following in part: Our community maintains and supervises the use of assistive devices and equipment for residents. 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan . 6. The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. B. Personal fit - the equipment or device is used only according to its intended purpose and is measured to fit the resident's size and weight.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 23 residents (Residents #42) reviewed for pharmacy services. The facility failed to ensure Midodrine (a low blood pressure medication) given to elevate hypotension (low blood pressure) was administered to Resident #42 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings include: Record review of Resident #42's admission face sheet dated 11/14/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #42 had diagnoses which included: rheumatoid lung disease with rheumatoid arthritis on multiple sites (a chronic inflammatory disorder affecting many joints), systemic lupus erythematosus (inflammatory disease caused when the immune system attacks its own tissues), pulmonary fibrosis ( scarring of the lung tissue), Sjogren syndrome ( an immune disorder characterized by dry eyes and dry mouth), hypertension (elevated blood pressure) and Percutaneous Endoscopic Gastrostomy (PEG) ( a flexible feeding tube placed through the abdominal wall to allow nutrition, fluids and medications to be put directly into the stomach). Record review of Resident #42's care plan date initiated 04/15/2022 reflected: Focus: Resident #42 had a diagnosis of altered cardiovascular status related to hypotension (heart condition related to low blood pressure) history. Goal: Resident will remain free from symptoms of cardiac problems through the review date. Interventions: Administer medications per physician's orders. Record review of Resident #42's quarterly MDS , dated 09/16/2023, reflected the resident's BIMS was scored at 15 out of 15, which indicated her cognition was intact. The resident had clear speech. The resident was able to make herself understood. The resident had the ability to understand others. The resident required extensive assistance of one staff for her bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS identified an active diagnosis of medically complex conditions. Record review of Resident #42's Medication Review Report, dated on or before 11/14/2023, reflected Midodrine 10 Mg. Give one tablet by PEG-tube three times a day for hypotension. Hold for systolic blood pressure (the top blood pressure number which measures the pressure in the arteries when the heart beats) greater than 130. Order start dated 02/17/2023. Record review of Resident #42's November 2023 Medication Administration Record, dated 11/01/2023 -11/30/2023, reflected the resident was not administered Midodrine 10 mg on the following dates due to parameters not met: 11/04/2023 at 4:00 PM with BP 110/74 and at 8:00 PM with BP 124/60 by LVN B 11/05/2023 at 8:00 PM with BP 128/70 by LVN B In an observation and interview on 11/14/2023 at 2:24 PM revealed Resident #42 was sitting in a wheelchair in her room. Resident #42 was alert and oriented. During an interview Resident #42 stated she had no concerns with her medications. In an interview and record review on 11/15/2023 at 9:25 AM, the DON reviewed Resident #42's MAR. The DON stated Resident #42 should have received the Midodrine if the resident's blood pressure was not greater than 130. The DON stated the documentation reflected the Midodrine was held due to blood pressure out of parameters. The DON stated Resident #42's blood pressure was not outside parameters. The DON stated the risk to the resident was her blood pressure could go low. The DON stated the nurse was responsible for medication administration accuracy. The DON stated the ADON was responsible for monitoring the medication administrations accuracy daily. The DON stated the results of the monitoring were discussed during the 24-hour meeting. In an observation and interview on 11/15/2023 at 9:46 AM revealed ADON M reviewed Resident #42' MAR. ADON M stated she monitored the medication administration record twice during her shift for accuracy. ADON M stated she did not see the Midodrine was held. ADON M stated the medication should have been given. ADON M stated the risk of not administering the medication was the resident's blood pressure could go lower. ADON M stated to prevent missing an error in the future, she would monitor the MAR closer. In a telephone interview on 11/15/2023 at 10:03 AM, the Pharmacist stated the medication Midodrine was to be given for low blood pressure. The Pharmacist stated when there was a parameter hold ordered by the physician the order was to be followed. The Pharmacist stated the blood pressure readings when medication was held were not severely low which would not be a bad outcome for the resident. In an interview on 11/15/2023 at 1:30 PM, the Administrator stated her expectations regarding the midodrine was the physician's order be followed. The Administrator stated the medication should not have been held for blood pressures less than 130. The Administrator stated the risk to the resident was her blood pressure could go low. The Administrator stated the medication administration records and physician's order would be monitored closer daily. In an interview on 11/15/2023 at 3:07 PM, LVN B stated when she administered medications, she reviewed the ordered parameters before she gave the medications. LVN B stated after record review of the medication administration record, she should not have given the medication. LVN B stated she may have been confused between the less than sign and the greater than sign. LVN B stated she would be more careful in the future with the two different signs. LVN B stated the risk to the resident was her blood pressure could be low. Record review of the facility policy titled Administering Medications, revised April 2019, reflected Policy heading Medications are administered in a safe and timely manner, and as prescribed .Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frames

Based on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 20 residents (Resident #85) reviewed for respiratory care. The facility failed to set the flow rate at 2 liters of oxygen per the order for Resident #85. This deficient practice could place residents at risk of incorrect or inadequate respiratory support and could result in a decline in health. Findings include: Record review of Resident #85's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included hypertensive heart disease with heart failure (left changes in the heart as a result of chronic elevated blood pressure), paroxysmal atrial fibrillation (intermittent rapid, erratic heart rate that stops on its own), Chronic systolic (congestive) heart failure (heart failure specific to the hearts left ventricular), presence of pacemaker, dyspnea (difficulty or labored breathing), and hyperkalemia (elevated potassium levels in the blood). Record review of Resident #85's quarterly MDS assessment, dated 10/25/2023, reflected she was assessed as having a BIMS of 10 out of 15, which indicated Resident #85 had moderate cognitive impairment. Section B indicted Resident #85 was usually understood and usually understood others . Section I identified Resident #85 had medically complex conditions. Section O did not reveal: Oxygen in use while in the facility. Record review of Resident #85's Medication Review Report, dated on or after date 11/14/2023, reflected Oxygen 2 liters as needed for shortness of breath. Order dated 03/08/2023. Record review of Resident #85's care plan, dated 11/15/2023, reflected the following: Focus: The resident had shortness of breath related to anxiety; Goal: The resident would maintain normal breathing pattens. Through the review date; Interventions: Apply oxygen as ordered. In an observation on 11/14/2023, at approximately, 8:45 AM revealed Resident # 85 was in bed with oxygen at 5 liters per nasal cannula (oxygen delivery device into the nose ). In an observation on 11/14/2023 at 1:57 PM revealed Resident #85 was in bed sleeping with oxygen per nasal cannula at 5 liters. In an observation and interview on 11/14/2023 at 2:57 PM, RN A stated she was taking care of Resident #85. RN A stated she checked the oxygen flow rate and the oxygen orders once a shift. RN A stated the nurse caring for the resident was responsible for the correct oxygen flow rate. RN A reviewed Resident #85's physician's order and stated the order was for 2 liters if needed for shortness of breath. RN A stated if the resident was short of breath and needed the flow rate higher the physician would be notified. RN A stated there would be a new order for the new rate. RN A stated if the resident needed a change that would be documented in the chart. RN A stated she did not see any changes in the resident's clinical record for a change in the oxygen. Observation at this time of Resident #85's oxygen, RN A stated the oxygen was set at 5 liters. RN A stated she had not checked Resident #85's oxygen yet on her shift. RN A stated the risk to the resident was CO2 retention (too much carbon dioxide in the blood could lead to a decreased level of consciousness). In an interview on 11/14/2023 at 3:08 PM, the DON stated the nurses were responsible for making sure the resident's oxygen flow rate was at the proper ordered rate. The DON stated the nurses were responsible for monitoring the oxygen flow rate and the physician's order every shift. The DON stated if a resident needed a change in the oxygen that would be documented in the chart. The DON stated the risk to the resident was high oxygen levels.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the refrigerator in that: The facility stored unlabeled foods in the refrigerator. This failure had the potential that could place residents at risk of serious complications from foodborne illness as a result of their compromised health status Findings include: Observation and interview on [DATE] starting at 9:07 a.m. of the walk-in freezer revealed 1 unlabeled bag of breadsticks, an unlabeled bag of what appeared to be frozen chicken, and another unlabeled bag of chicken. The Dietary Manager identified the contents of the unlabeled bags of food. She stated that the bags should be labeled and that she should have checked that. She stated, That food needed to be labeled so that residents are not served food that has gone beyond the expiration date and that it's safe for the residents. Leftovers can be stored in the refrigerator for 72 hours, and food unopened can be stored for a week. Interview with the Director of Food Services Supervisor on [DATE] at 10:08 a.m., stated that the policy for storing food is everything should have been labeled and dated. The Director of Food Services Supervisor stated in the refrigerator, everything should have been labeled with the date it arrived and date opened. The Director of Food Services Supervisor previously stated that on [DATE] at 9:07 a.m., she was supposed to have checked that, referring to labeling and dating the items on the bags of food that were unlabeled. Record review of the Facility's Food Storage policy dated [DATE] stated, to ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated .f. Where possible, items are left in the original cartons placed with the date visible . g. The first-in, first-out rotation method is used. Packages are dated and new items are placed behind existing supplies, so that older items are used first .e. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. All leftovers are used within 48 hours. Items that are over 48 hours old are discarded .e. Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated . Record review of in-services or trainings revealed the following: tr Food Storage dated [DATE], Food storage & Cooling & Reheating foods- Label and Dating dated [DATE], In-service training on Hazardous foods Stored Properly dated [DATE], In-service training on All Foods off Floor, dated, not expired dated [DATE], In-service training on Label & Dating dated [DATE], In-service training on All Foods covered, Labeled, Dated, Open dated in Fridge dated [DATE].

Based on observation, interview and record review, the facility failed to ensure services provided, met professional standard of quality for 2 (Resident #15 and #67) of 20 residents assessed for physician's order in that: The facility failed to follow Resident #15's physician's order to hold blood pressure (BP) medication when his blood pressure was below the ordered parameter. The facility failed to follow Resident #67's best practice, policy and procedure for labeling formula at bedside when administered. These failures could place residents at risk of not receiving the care and services ordered by the physician and a decline in health status. Findings Included: Resident #15 Record review of Resident #15's admission face sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] . His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's physician's order summary report revealed [MEDICATION(S)] 0.3 mg Give one tablet by mouth every eight hours for hypertension. Hold for BP less than 130/70. The order was dated 03/02/2022. Record review of Resident #15's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 which indicted his cognition was moderately impaired. The MDS revealed one of Resident #15's active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #15's care plan dated 06/15/2022 read in part: Focus: The resident has altered cardiovascular status related to congested heart failure, hypertension, coronary artery disease, [CONDITION(S)]. Goal: The resident will be free of complications of cardiac problems. Interventions: Give all cardiac medications as ordered by the physician. Record review of Resident #15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold for Blood Pressure (BP) less than 130/70. Continued review of Resident #15's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 08/01/2022 at 4:00 PM BP was 128/70 08/02/2022 at 4:00 PM BP was 109/64 08/03/2022 at 4:00 PM BP was 128/63 08/04/2022 at 12:00 AM BP was 120/64 and 8:00 AM BP was 128/63 08/05/2022 at12:00 AM BP was 128/63 08/06/2022 at 12:00 AM BP was 123/68 In a telephone interview on 08/17/2022 at 3:44PM , MA A stated the check mark and her initials on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MA A stated when she gave blood pressure medications, she checked the resident's blood pressure first, then she reviewed the MAR for any parameters. If she saw the blood pressure was too low, she would not give the medication. MA A stated she would discuss the issues with the nurse on duty. MA A stated she did not remember who she spoke with but if she was told to give the medicine then she would. MA A stated the risk of giving the blood pressure medication outside the ordered parameters it could cause the resident's blood pressure to drop. In a telephone interview on 08/17/2022 at 3:59 PM , MA B stated the check mark and the initials on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MA B stated her process to give blood pressure medications was to check the blood pressure first, then check the MAR for the parameters. MA B stated if she found the resident's blood pressure was below the parameter, she would not give the medications. The risk of giving the medications outside the parameter was it could cause the resident's blood pressure to drop low. MA B stated she should not have administered the medication when the blood pressure was below the parameter. MA B stated that going forward, she would pay more attention, but it must have been an oversight. In an observation and interview on 08/18/2022 at 9:45AM , Resident #15 was sitting up in bed awake and alert. Resident #15 stated he was doing well, and he was getting his medications alright. Resident #15 stated the staff was taking his blood pressure before he got his medications. In an interview on 08/18/2022 at 9:55AM, RN C stated the check mark on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C stated when blood pressure medications were administered, the staff first check the blood pressure and check to see if there were parameters to hold the medication ordered by the physician. He stated if the blood pressure was below the parameter, the medication was held. The risk of giving the medication was it could cause the resident's blood pressure to go too low. In an interview on 08/18/2022 at 10:02 AM, the DON stated the expectation was the blood pressure medications were to be given when within the parameters ordered. The medications were not expected to be given when outside the parameter. The DON stated this was important because there was a risk the resident's blood pressure could go too low. Our plan to prevent this from occurring again was to educate and review all resident medication administration records. In an interview on 08/18/2022 at 10:28 AM, with the Administrator she stated she was not clinical, but her expectations were the physician's ordered were followed for administering medications. She stated she was unable to answer what the risk was to the resident if blood pressure medications were administered outside the physician's ordered parameter. The Administrator stated the plan to prevent this from occurring again was to audit all resident's medication records and educate the staff on administering blood pressure medications. The Administrator stated Resident #15's physician was notified of the issue. In a telephone interview with Resident #15's physician, he stated the parameters for the resident's [MEDICATION(S)] (blood pressure medication) was set high because he thought the medication maybe too strong for the resident but the resident did not have any problems from it, so he will lower the parameter. The risk of giving the medication outside the parameter was the resident's blood pressure could drop too low, but Resident #15's did not. Resident #67 Record review of Resident #67's admission face sheet revealed he is a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Dementia (is the loss of cognitive functioning - thinking, remembering, and reasoning), Obstructive [CONDITION(S)] (excess fluid build-up in fluid-containing cavities of the brain, which results in developmental, physical, and intellectual impairments). Record review of Resident #67's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 which indicted he was unable to participate in assessment. The MDS revealed Resident #67's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/16/22 at 9:27 am, Resident #67 was lying in bed with HOB raised and his eyes closed. The tube feeding machine was noted a hist bedside, but was not infusing and without writing on label as to date/time/rate hung/administered by staff member. In an interview and observation during med pass on 8/17/22 7:09 am, RN D observed the enteral formula should have been labeled by nurse from previous shift with name of resident, time or date when enteral product was hung. When asked why they placed residents' name, drug, dose, time and date when hanging enteral product, she stated to assure correct residence, correct formula, correct time, correct dose. When I asked why it's important to do this, she reported the milk could spoil and harm resident. In an interview on 8/17/22 2:00 pm with the DON, she stated in best practice nursing, the nurse would have checked orders and placed the information the on label: resident's name, type of formula, date and time formula was hung, rate of administration. The DON stated the information placed in the residents' chart would be: resident's name, type of formula, date and time formula was hung, rate of administration. The DON handed the Policy and Procedure: Enteral Tube Feeding via Continuous Pump Revised dated November 2018,to the surveyor, and reviewed policy and procedure regarding enteral feeding via continuous pump. When asked why the nurse should have labeled the formula, she stated it was best practice to label the enteral product when it was hung. When asked where was resident name, type of formula, date and time formula was hung, rate of administration documented, she stated it was documented on the label of the enteral formula at bedside and on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Called LVN D, 08/18/22 10:43 am left message with request for call back with call back number, regarding enteral formula not being labeled with initials, date and time the formula was hung/administered, and initial that the label was checked against the order as observed on 8/17/22 during medication administration with RN D. Record review of the facility policy titled Policy and Procedure: Enteral Tube Feeding via Continuous Pump Revised dated November 2018 read in part .Section: Initiate feeding #5, states On the formula labeled document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Record review of the facility policy titled Administering Medications Revised dated April 2019 read in part . Policy Statement Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame .

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to report to the State Agency and one or more law enforcement entities, any reasonable suspicion of a crime against any individual who was a resident of, or was receiving care from, the facility for 1 of 17 residents (CR#1) reviewed for abuse and neglect. -The facility failed to immediately report an allegation of abuse/neglect when unwitnessed injuries with unknown origin to the State Office and law enforcement which included: - CR#1 was observed on 3/30/22 with a dark purple bruise on her sternum (between breast), left breast, which went towards her back, her middle finger and her left ankle. CR#1 had bruising from an unknown source. The facility staff did not immediately notify the administrator until five days later on 4/4/22. This failure placed residents in the facility at risk for abuse/neglect not being reported to outside regulators for thorough investigations could be conducted which could cause further abuse/neglect, inaccurate tracking and this could increase the probability that allegations of abuse and neglect would go unrecognized. Findings included: Record review of CR#1's face sheet dated 4/7/22, revealed [AGE] year-old female, who admitted to the facility on [DATE] and discharged to the hospital on 4/4/22. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR#1's quarterly MDS dated [DATE] indicated a BIMS of 3, indicating severe cognitive impairment. Further review of CR#1's MDS indicated she required extensive assistance with two staff members for bed mobility, transfers and toileting. CR#1 required extensive assistance from one staff member for personal hygiene. Record review of CR#1's care plan dated 1/26/22 indicated CR#1 had an ADL self-care performance deficit related to dementia. Interventions included assist with ADLs. Record review of CR#1's care plan with an initiation date of 4/4/22 indicated she had potential discolorations of bruising impairment to skin integrity of the left inner chest, right dorsal fort (inward side of the foot), left 2nd back hand, left inner arm, left inner chest and left chest area bruising. Goals indicated: resident will maintain or develop clean and intact skin; the resident will be free from injury or bruise to right chest area and the resident skin injury bruise of the right chest will be resolved. Interventions include encourage good nutrition and hydration to promote healthier skin, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of CR#1's Change in Condition Evaluation dated 4/4/22 written by LVN C read in part, Signs & Symptoms Identified: Change in skin color or condition. This started on 4/4/22 . Resident has dark bruising, purple in nature at sternum, left upper arm, below left breast, and left side of back. Resident also has [CONDITION(S)] both feet and bruising to inside of both lower legs . Record review of CR#'1s nursing note dated 4/4/22 written by LVN C read, CNA brought this charge nurse into the room. Resident in bed bruising evident to sternum area, extending under left breast, down the inside of the left arm from armpit to elbow, across the left side of the back. Both feet are red, swollen and a bruise is observed to the inside of the left leg about the left ankle . In an interview on 4/7/22 at 9:34 AM with CR#1's roommate, she said CR#1 was pretty quiet and stuck to herself. She said CR#1 didn't have any issues that she's aware of and not sure of any recent falls. CR#1's roommate said the day before she went to the hospital (4/3/22) someone came to get blood but they were not able to do so, but she doesn't know why, only that the roommate couldn't give blood. CR#1's roommate said she was not sure why she was sent to the hospital. In an interview on 4/7/22 at 9:37 AM with CNA A she said she worked with CR#1 on 3/30/22 and was taking her to have a shower. She said she was taking CR#1's clothes off in the shower and noticed the bruising to her chest. She said she seen a bruise on her chest, left breast, going towards her back, on her middle finger, and left ankle. CNA A said she immediately went to get LVN B to show him the bruising, as she had not noticed it before. She said she is not aware of CR#1 having any recent falls. Record review of CR#'1s nursing notes indicated no note written by LVN B on 3/30/22 regarding any bruising for CR#1. In an interview on 4/7/22 at 11:09 AM with LVN B he said on 3/30/22 CNA A came to get him so that he could see the bruising that CR#1 had in different areas of her body. He said the bruising was purple in color, but faded, so it did not look new. He said CR#1 does have a tendency to scream a lot when staff work with her. He stated he was not aware of any recent falls for CR#1 may have had. LVN B stated CR#1 was on blood thinners, which could cause the bruising to her body. He said when he left the shower room he was still doing other task, got distracted and forgot to report the bruising of CR#1 to the administrator or DON .LVN B said he is trained to report all abuse and neglect to the administrator and is suppose to complete a full body assessment and complete a note in the residents chart regarding findings. Record review of CR#1's recent nursing assessments indicated no nursing assessment completed on 3/30/22. In an interview on 4/7/22 at 12:26 PM with CNA E she said on Monday morning, 4/4/22, she was assigned to the front of the 400 hall and CNA D was assigned to the back, where CR#1 lives. She said before breakfast, her and CNA D were both doing showers when CNA D asked her to help transfer CR#1 back to her room. She said they got CR#1 back into her room, and she saw all the bruising on her left side. She said CNA D went to go get the nurse, LVN C, who came to assess CR#1. CNA E was not aware of any falls that CR#1 may have had. She said when they would touch the bruising, CR#1 did wince of pain. In an interview on 4/7/22 at 12:39 PM with LVN C, she said on Monday (4/4/22) she was the charge nurse for CR#1. She said around 8 AM, CNA D took CR#1 to the room, she came to get her so she could look at the bruising that was on the left side, in different areas on CR#1's body . LVN C said when she completed her assessment, there were dark extensive areas on the right breast, upper arm, edges of her back and it was also on her feet and lower legs. She said CR#1 had [CONDITION(S)] was on both feet and bruising to lower legs. LVN C said she went to get the ADON, and they started doing a head-to-toe assessment and change in condition form. She said she was not made aware of the bruising before Monday. LVN C said she received orders to get a chest x-ray and labs, but CR#1's family requested that she be sent to the hospital for further evaluation . LVN C said she is not aware of CR#1 having any recent falls. In an interview on 4/7/22 at 12:46 PM with the ADON, he said he was working on the floor on Monday (4/4/22) and LVN C came to get him and informed him that CR#1 had bruising in different areas on her left side. He said he went with LVN C to CR#1's room to complete a skin assessment on CR#1. The ADON said he told LVN C to notify the administrator, the doctor and CR#1's family. He said when he saw the bruising on CR#1, it was underneath her left breast and left arm. He said CR#1 was unable to say if anything hurts. CR#1 did not complain of pain but didn't want anyone to touch her. The ADON said he was not made aware of the bruising on CR#1 before Monday. The ADON said the staff are in-serviced by the administrator on reporting abuse to her, as she is the abuse coordinator. In an interview on 4/7/22 at 1:19 PM with CNA D she said on 4/4/22 when she was going to give CR#1 a shower, she took her gown off and saw the bruising on the left side of her body. She said the bruising was in the middle of her chest, under her breast towards her back, under her armpit and on her ankles. She said her ankles were also swollen. CNA D said it was a dark purple/blue color, as if it happened within a last couple days. She said she notified LVN C about the bruising on CR#1 and they completed a skin assessment on her. CNA D said she did not know about the bruising on CR#1 until she worked with her on 4/4/22. In an interview on 4/7/22 at 1:22 PM with CNA F she said she worked with CR#1 on 3/31/22 she said she didn't notice anything on CR#1 while she was working with her. She said she worked Thursday morning and she changed her pants, but not her shirt. CNA F said she only got CR#1 up during the morning and another CNA put her back in bed while she was on lunch. CNA F said she does not recall anything on CR#1's legs when she was changing her clothes. She said CNA A assisted her while CR#1 was in the bed and helped with providing her ADL care. CNA F said she is was not aware of CR#1 having any recent falls. In an interview on 4/7/22 at 2:20 PM with CNA H she said she worked with CR#1 on Friday, April 1st, 2022. She said she usually can assist CR#1 by herself but had to receive help to get her up. She said CR#1 was screaming as if she was in pain, so she decided to let her stay in the bed and notified the nurse to address CR#1's pain. CNA H said she worked with CR#1 and noticed the bruising on 4/1/22. She said CR#1 had a large purple bruise on her chest and was informed by CNA A that management was aware. She said CNA A helped her with CR#1 said, don't worry about reporting the bruise on her chest, they already know about it. CNA H said she did notice the redness on CR#1's legs and the bruise under her breast, that was a little yellow. CNA H said CNA A did not tell her what happened, she only told her not to worry about it as the facility already knew about it. CNA H said she is trained to report abuse, neglect or injuries to the administrator, who is the abuse coordinator, but thought since CNA A said it was reported, she did not need to notify the administrator. In an interview on 4/7/22 at 2:36 PM with the DON, she said she was made aware on Monday (4/4/22), by LVN C and the ADON about the bruising on CR#1. She said when she went to see CR#1, she had bruising from her chest/breast area and discoloration on her lower legs. The DON said she believes the bruising may be from an improper transfer. The DON said she believes this due to the place of the bruising and believes the staff may have had their hand too tight on her, which caused the bruising. She said the administrator conducts the abuse and neglect training and staff are continuously in-serviced on reporting anything out of the ordinary to the administrator. In an interview on 4/7/22 at 2:41 with the Administrator, she said she was not made aware of the bruising of CR#1 until Monday, 4/4/22. She said when LVN B and CNA A found the bruising on 3/30/22, it should have been reported immediately. She also said all staff that worked with CR#1 from 3/30/22 through 4/3/22 should have reported the bruising that was noted on CR#1 so that an immediate investigation could begin. The administrator said she believes the bruising occurred from an improper transfer and training has been completed regarding proper transfers. The administrator said she completes the training for abuse, neglect, exploitation, and staff are to report things to her. The facility initiated the self-report to the State on 4/4/22. Record review of the facility Abuse Policy 2019 read in part, It is the responsibility of our facility employees/associates, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected resident neglect or reside abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management . in the absence of the facility abuse coordinator, such reports may be made to the Director of Nursing Services and if not available then to the nurse supervisor on duty .

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles and under proper temperature controls for 1 of 1 medication storage rooms and 4 of 4 medication carts reviewed for medication storage. The facility failed to ensure: - Medications and supplements in the medication storage room were appropriately labeled and not expired - The medication aide cart on the 100-Hall did not contain loose pills and medications/supplements were stored within manufacturer specified temperature ranges. - Medications and supplements in the 300-Hall nurse and medication aide carts were stored within manufacturer specified temperature ranges. - Supplements in the 300 and 400-Hall nurse carts were used within manufacturer specified beyond use dates. These failures could place residents at risk of not receiving the therapeutic benefit of medications or an adverse reaction to medications. Findings include: Medication Storage Room In an observation and interview on 06/09/21 at 09:25 AM, inventory of the medication storage room with the DON revealed: - An undated open bottle of Med Pass 2.0 with manufacturer storage instructions of After open, consume product within 4 days if properly refrigerated in the refrigerator. The DON said that all multi-dose medications and supplements should be labeled upon opening and used within the specified manufacturer beyond use date. The DON said if the open date is not documented it is not possible to determine if a medication or supplement is within its beyond use date so it should be discarded in the drug destruction bin. The DON said since the box of Med Pass 2.0 did not have an open date it should be discarded in the drug disposal bin. 100- Hall Medication Aide Cart In an observation and interview on 06/09/21 at 09:52 AM, inventory of the 100-hall medication aide cart with MA S revealed: - 4 ½ loose pills - Bottle of Acidophilus, a [MEDICATION(S)], with open date of 03/19/21 with manufacturer instructions of REFRIGERATE AFTER OPENING stored at room temperature. MA S said that there was no facility policy specifying how often medication carts should be checked for loose pills, appropriate storage conditions and expired medications but she checks her cart weekly. MA S said all medications/supplements should be stored under specified manufacturer conditions and if not, they should be discarded in the drug destruction bin located in the med room. MA S said she did not know that specific manufacturer of Acidophilus had to be refrigerated and since it was not it had to be discarded. MA S said all loose pills should be discarded in the sharps container. 300-Hall Medication Aide Cart In an observation and interview on 06/09/21 at 10:05AM, inventory of the 300-hall medication aide cart with MA B revealed: - 1 open bottle of Acidophilus, a [MEDICATION(S)], with open date of 05/29/21 with manufacturer instructions of REFRIGERATE AFTER OPENING stored at room temperature. MA B said that she did not know that bottles of Acidophilus had to be refrigerated after opening and since it was at room temperature it could not be used. MA B said all loose pills, expired medications and medications kept outside of manufacturer specified storage parameters should be discarded in the drug disposal bin in the medication storage room. 300-Hall Nursing Cart In an observation and interview on 06/09/21 at 09:32 AM, inventory of the 300-hall medication aide cart with RN L revealed: - 2 loose pills - 1 expired bottle of Active Liquid Protein, a protein supplement, with open date of 02/18/21 with manufacturer instructions of 3-month shelf life from date opened. RN L said she was not aware that the protein supplement had a shelf life of 3 months after opening. RN L said liquid medications should be dated on the day they are opened and used within the manufacturers specified timeline. RN L said that since the protein supplement was opened on 02/18/21 the last day of use should have been 05/18/21 and it should have been discarded in the drug disposal bin after that day. 400-Hall Nursing Cart In an observation and interview on 06/09/21 at 10:05AM, inventory of the 300-hall medication aide cart with LVN H revealed: - 2 expired bottles of Active Liquid Protein, a protein supplement, with open dates of 11/10/20 and 12/16/20 and with manufacturer instructions of 3-month shelf life from date opened. LVN H said that medication carts should be checked for loose pills and expired medications. LVN H said loose pills are discarded in the sharps containers and expired medications are discarded in the drug destruction bin. LVN H said all liquid medications or supplements should be dated on the day opened, stored as instructed by the manufacturer and used before the beyond use date. LVN H said she did not know that the protein supplement had a 3-month shelf life and thought it could be used until the printed expiration date. LVN H said since the protein supplement was past its 3-month shelf life it should be discarded in the drug disposal bin. In an interview on 06/09/21 at 01:00 PM, the DON said loose pills should be discarded whole or crushed in the sharps containers and prior to returning medications or supplements to the cart staff are expected to verify that the item is being stored as instructed by the manufacturer. The DON said that medications and supplements that require refrigeration should be stored in the medication storage room refrigerator and all liquid medications and supplements are expected to be dated with the day received, the date opened and used within the manufacturer specified beyond use date. The DON said there was not a facility policy that specified the frequency at which medication carts should be inspected for loose pills, expired medications and medications outside of manufacturer storage parameters but staff are expected to go inspect and clean their carts weekly and expired medications should be pulled daily and discarded in the drug destruction bin. Record review of facility policy Storage of Medications revised November 2020 revealed: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 4- Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 7- Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or other secured location. Record review of facility policy Administering Medications revised April 2019 revealed: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 2 of 2 residents (Residents #6 and #50) reviewed for PASRR Level 1 screenings. The facility did not send the correct PASRR Level 1 screening to the local authority for Residents #6 and #50. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Resident #6 Record review of Resident #6's admission record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's PASRR level 1 screening dated 3-12-2021 revealed Resident #6 was negative for mental illness, intellectual disability, and developmental disability. Record review of Resident #6's admission Minimum Data Set (MDS) dated [DATE] revealed in part: Brief Interview of Mental Status (BIMS) unable to be completed with a score of 99. The staff assessed her cognitive skills for daily decision making at 3 which indicated severely impaired. Resident #6 required extensive assistance of two people for bed mobility. She required total assistance of two people for transfer. She required total assistance of one person for toileting, personal hygiene, dressing, locomotion on/off unit, and bathing. The resident was always incontinent of bladder and bowel. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] sprinkles capsule delayed release sprinkle 125 mg give two capsules by mouth three times a day for anxiety. Antipsychotic monitoring every shift for side effects. Antidepressant monitoring every shift for side effects. Behavior Monitoring for medication: [MEDICATION(S)]. Behavior monitoring for medication: [MEDICATION(S)]. Record review of resident #6's care plan initiated on 4/26/2021 read the resident uses anti-anxiety medications (Lorazepam) due to anxiety disorder. Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-shift. Record review of resident #6's care plan initiated on 6/5/2021 read the resident uses [CONDITION(S)] medications due to [CONDITION(S)], behaviors, depression, and [CONDITION(S)]. Administer [CONDITION(S)] medications as ordered by physician. Monitor for side effects and effectiveness. Resident #50 Record review of Resident #50's admission record revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #50's PASRR level 1 dated 11/13/2020 was negative for mental illness, intellectual disability, and developmental disability. Record review of Resident # 50's quarterly MDS dated [DATE] revealed she had a BIMS of 15 out of 15 indicating no cognitive impairment. The mood section indicated she had a score of 6 out of 27 indicating some depressive symptoms. She required total assistance of 2 or more people for bed mobility. She required total assistance of one person for toileting, personal hygiene, dressing and eating. She is always inconstant of bowel. Her active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #50's June medication administration orders read [MEDICATION(S)] hcl ER tablet extended release 24-hour 150 mg give 1 tablet by mouth at bedtime for depression. Record review of Resident #50's care plan initiated 11/23/2020 read the resident uses antidepressant medication due to depression. Initiated date 6/04/2021 The resident uses anti-anxiety medications due to anxiety disorder. In an interview on 6/10/2021 at 12:30 p.m., MDS LVN D stated she did a training webinar on PASRRs and it was very confusing. She stated only residents who had been in a psych hospital with behaviors would qualify for PASRR. She said she did not understand about diagnosis. In an interview with the Administrator on 6/11/2021 at 10:00 a.m., she stated that they hand the PASRR Level I's to MDS LVN D and tell her to put them into the portal. She said she will remind her to look at resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Texas Health and Human Services PASRR guidance provided by the Administrator 6/11/2021 at 9:00 AM revealed it was it was an item by item guide for completing the PASRR Level I screening Form Version 1.4 update June 2019. It read in part The PASRR Level I screening form is designed to identify person who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD) also referred to as related conditions (RC). The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID, DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individuals level of functioning.

Based on interview and record review, the facility failed to ensure the resident mail was delivered promptly and unopened for 1 of 18 residents (Resident #59) reviewed for resident rights. The facility did not ensure the security of Resident #59's mail after delivery from the post office, he received his mail opened. This failure could place residents at risk of not receiving mail in a prompt and private manner and could result in a loss of personal property, frustration and loss of dignity for the residents who reside at the facility. Findings included: Record review of a face sheet dated 05/05/21 indicated Resident #59 was [AGE] years old, admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #59's annual MDS, dated [DATE], revealed a BIMS score of 15, which indicated intact cognition, he also required extensive assistance with Activities of Daily Living. Record review of Facility Grievance/Concern report dated 05/05/2021 indicated that Resident #59 expressed allegation of missing $250 cash. Further review of the investigation carried out by the facility indicated that on 5/5/2021, the Activities Director reported Resident #59's envelope that was mailed to him was found opened. Resident #59 was interviewed by the administrator and the activities director and he stated that his friend mailed an envelope to him containing $250 cash along with a check to cover his rent. The Administrator contacted Resident #59's friend who confirmed that he mailed an envelope addressed to him containing his rent check and the sum of $250 Cash on 5/1/2021. During an interview on 06/08/21 at 11:45 AM, Resident #59 said his friend sent him an envelope containing his monthly rent and $250 cash. However, when the envelope was giving to him by the activities director, it was not sealed. He said he cannot remember the exact date or time, but the incident happened around the first week of May. He said he called his friend who confirmed that the envelope contained his monthly rent and a sum of $250 cash. He said the facility notified the police who came around and did some investigation. He said the facility declined taking responsibility for the missing cash and was told they found the envelope unsealed. The facility informed him that they were going to investigate, but the money was not found neither was it replaced. This was not the first-time money was sent to him by his friend. He showed the surveyor the envelop and it was addressed to him on 01/05/2021. Attempted to contact Resident #59's friend via phone on 06/09/2021 at 10:50 AM was unsuccessful. During an Interview on 06/09/21 at 11:15 AM, the Business Manager said she is responsible for picking up all the facility mail from the mail box located outside the facility. Her daily morning routine involves picking up the mail from the outside mailbox and distributing them to the different department boxes located in the printer room inside the facility. She said she picked up all the mail on 05/04/21 and saw Resident #59 mail was sealed and she placed it in the box of the activities department. She said the Activities Director is responsible for distributing all resident's mail. She said the next day the Activities Director notified her that she found the envelop for Resident #59 opened when she picked it up on 05/05/2021 she advised her to speak to the administrator immediately as the envelope was not opened when she picked it up from the outside mail box the previous day. She said everyone in the facility has access to the printer room door code, the printer room is always kept open during the day and locked after hours. During an Interview on 06/09/21 at 11:25 AM, the Activities Director said she was able to recall the incident with Resident #59. She said her daily routine is to pick up resident's mail in the morning from the printer room and distribute it to all the residents. She said the business manager retrieves all the mail for the facility from the outside mailbox and brings them to the printer room and places them in the different department's boxes. She said she is the only one responsible for distributing residents' mail to their respective rooms. She said she cannot remember the exact date the incident happened, but she picked up the envelope in the morning in the printer room and found Resident #59's envelope opened. She immediately contacted the business manager and notified her. The business manager told the Activity Director that the mail was sealed when she picked it up from the outside mailbox. She went ahead and notified the social worker and the facility administrator. She said only the check was found in the envelope, but cash was not found. She said the facility policy does not permit her to open resident mail and mail should be delivered unopened. She said there have not been any other incidents reported of this nature since she has been at this facility. During an Interview on 06/09/21 at 11:32 AM, the Social Worker said she had been at the facility for over a year and gets to interact with the residents daily. She said she is familiar with Resident #59, she describes him as alert, oriented, and generally pleasant. She remembers the incident but was unable to remember the exact date, she said the activities director notified her of the opened mail belonging to Resident #59. She looked inside of the mail and found only the check and no cash was inside. She advised the activities director to speak to the administrator. The administrator investigated, and a report of theft was filed with the Police. She said the activities director is responsible for distributing the mails to all the residents. During an interview on 06/09/21 at 12:22 PM, the Administrator said that the Activities director informed her on 05/05/2021 over the phone that the envelop belonging to Resident #59 was opened. She said it was taken to him and he said there was supposed to be $250 in the envelope together with his monthly rent check. She reached out to the friend who sent the envelope and confirmed he sent $250 cash including the check. She said residents have the right to receive their mail in the facility. The business office manager picks up the mail from the outside mailbox and takes them to the workroom and distributes it to different department boxes. Before the incident, the workroom that houses the printer and mail was always left open 24hrs, and everyone had access to the workroom. She said only the activities director can distribute residents' mail. The business office manager confirmed that the envelope was unopened when she picked up the mail from the outside mailbox on 5/4/21. The mail was in the printer room all night before it got picked up by the activities director on 05/05/21 who found it opened. The facility investigated and interviews staff, but no one confirmed they opened the envelope. She said Resident #59 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #59 is responsible for his finances. She said from the investigation conducted by the facility, they were unable to confirm if the cash was in the envelope when it was delivered because the cash was not seen by any staff member. She confirmed that someone opened the envelope in the facility but did not know who did it. The facility does not have a policy on refunds for residents and she said that the facility policy is to deliver residents mail unopened. During an interview over the phone on 06/11/21 at 09:29 AM, Resident #59 said he had been transferred to another facility and no one have reached out to him with respect to his missing $250. Record review of facility policy titled Mail and Electronic Communication revised May 2017 read in part: Residents are allowed to communicate Privately with Individuals of their choice and may send and receive Personal mail, email and other electronic forms of communication confidentially. Mail will be delivered to the resident Unopened Staff members of this facility will not open mail for the resident unless the resident request them to do so. (Such request will be documented in the resident's plan of care). Mail and packages will be delivered to the resident.