Every finding on record at Ebony Lake Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 1 (Resident's #1) CNA A failed to wash her hands or use hand sanitizer between change of gloves change while providing perineal care for Resident #1. The failure could place residents at risk for spread of infection and cross contamination.Findings include: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (complete paralysis and weakness on one side of the body are common, often debilitating, effects of a stroke). Record review of Resident #1's quarterly MDS assessment, dated 3/25/26 reflected BIMS(Brief Interview for Mental Status) score of 12, indicated cognition was moderate impaired. Section GG revealed Resident #1 was dependent for toileting hygiene (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan dated 12/24/24 reflected a focus area that Resident #1 had an ADL self-care performance deficit related to limited mobility, hemiplegia, hemiparesis. Bed mobility: the resident is dependent by times 2 staff to turn and reposition in bed. During an observation on 4/28/26 at 2:15 p.m., revealed CNA A and CNA B entered Resident #1's room and placed supplies on the bedside table. CNA A washed her hands, donned a gown and gloves. CNA A removed Resident #1's soiled brief and placed it in the trash can. CNA A removed her gloves and donned gloves without washing or sanitizing her hands. CNA A then cleaned Resident #1's peri-area, removed her gloves, but did not wash or sanitize her hands before donning new gloves. CNA A and CNA B washed their hands before and after the procedure only. During an interview on 4/28/26 at 2:25 p.m., with CNA A, she stated I should have sanitized or washed my hands before donning new gloves. She stated she should have washed her hands or used hand sanitizer between glove changes. CNA A stated, I forgot about it because I was nervous. She stated the potential negative outcome could be a spread of infection. She stated she had training on infection control, and handwashing. During an interview on 4/29/26 at 5:53 p.m., with the DON, she stated hands should be washed if gloves were visibly soiled or staff could use hand sanitizer between glove changes. She stated the ADON and DON were responsible for monitoring the staff for compliance with infection control. She stated the potential negative outcome could be cross contamination or infection even though the staff had the gloves as a barrier, they still could contaminate or give the resident an infection. Review of facility's policy on Infection Prevention Control Program with a date implemented 5/13/23 revealed This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Review of the Center for Disease Control and Prevention website, on 5/6/26 (https://www.cdc.gov/handhygiene/providers/index.html), Know when to clean your hands:Immediately before touching a patient.Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or patient's surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.

Based on observation, interview, and interview the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objectives and time frames to meet resident's mental and psychosocial needs for 1 (Resident #1) of 3 residents. The facility failed to develop a care plan to address Resident #1's the use of a mechanical lift during transfer. This failure places the resident at risk of inappropriate transfers with resulting injury. The findings included: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (complete paralysis and weakness on one side of the body are common, often debilitating, effects of a stroke). Record review of Resident #1's quarterly MDS assessment, dated 3/25/26 reflected BIMS score of 12, indicated cognition was moderate impaired. Section GG revealed Resident #1 was dependent for toileting hygiene (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan dated 12/24/24 reflected a focus area that Resident #1 had an ADL self-care performance deficit related to limited mobility, hemiplegia, hemiparesis. Transfer: the resident is dependent by times 2 staff to transfer Resident #1. This care plan did not specify the use of a mechanical lift. Record review of electronic progress notes dated 4/9/2026 06:15 a.m., revealed authored by LVN C CALLED BY CNAS UPON ENTERING RESIDENT ROOM, RESIDENT ON THE FLOOR ON HIS LEFT SIDE. CNAS WERE PROVIDING PATIENT CARE, WHEN RESIDENT GRABBED HIMSELF FROM MATTRESS AND ROLLED OVER TO THE RIGHT SIDE LANDING ON HIS RIGHT SIDE. ASSESSED RESIDENT HEAD TO TOE ASSESSMENT, LEFT LOWER SHOULDER BLADE SCRATCH, NO PAIN OR DISCOMFORT NOTED. NO BRUISING OR SKIN TEAR NOTED. During an interview on 4/28/26 at 1:55 p.m., LVN D stated Resident #1 required a 2 person mechanical lift transfer and for bed mobility. LVN D stated CNAs could find the type of transfers each resident required under their care plan. LVN D referred to Resident #1's care plan and stated the 2 person mechanical lift transfer was not indicated on Resident #1's care plan. LVN D stated CNAs could ask nurses about transfers if unsure and nurses would advise/educate CNAs on special transfers. LVN D stated MDS nurses were the people in charge of updating care pans. LVN D stated that by using one person assistance for bed mobility Resident #1 could have injured himself. During interview on 4/29/26 at 3:56 p.m., the MDS Nurse stated the MDS nurses were in charge of creating individualized care plans for residents. The MDS Nurse stated that care plans were created within 48 hours of admission, re- assessed after 14 days of admission, quarterly and as needed when change of condition has occurred. The MDS Nurse stated that Resident #1 needed a 2 person mechanical lift transfer. The MDS Nurse said that a mechanical lift transfer was something that would be included in a resident's care plan to provide appropriate and safe transfer that a resident may require. The MDS Nurse referenced Resident #1's care plan and stated there was no indication of a 2 person mechanical lift transfer. The MDS Nurse stated that by not being included, CNAs may not know the proper transfer needed and if not verified with a nurse a wrong transfer may be completed and result in some type of injury. The MDS Nurse did not know why type of transfer was not included in Resident #1's care plan. During an interview on 4/29/26 at 5:53 p.m., the DON stated the MDS nurse was in charge of creating individualized care plans. The DON stated care plans were created upon admission within 48 hours, updated 14 days after admission, quarterly, and upon change of condition. The DON stated failure to update proper information for example transfer type could result in a wrong transfer and potentially result in a potential accident. The DON did not know why Resident #1's care plan did not include the transfer type. The DON stated mechanical lift transfers were included in care plans for CNAs to reference and carry out proper care residents required. Record review of the facility's policy titled Comprehensive Care Plans with implemented date 10/24/22 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that incudes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment

Based on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being repositioned in bed for 1 (Resident #1) of 3 residents reviewed for accidents and hazards, CNA E failed to use two staff assist as required by Resident #1's care plan for bed mobility Resident #1 sustained a fall, on 4/9/26. This deficient practice has the potential to affect all residents in the building who require assistance with bed mobility by 2 staff members by causing falls and injuries. Findings included: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (complete paralysis and weakness on one side of the body are common, often debilitating, effects of a stroke). Record review of Resident #1's quarterly MDS assessment, dated 3/25/26 reflected BIMS(Brief Interview for Mental Status) score of 12, indicated cognition was moderate impaired. Section GG revealed Resident #1 was dependent for toileting hygiene (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan dated 12/24/24 reflected a focus area that Resident #1 had an ADL self-care performance deficit related to limited mobility, hemiplegia, hemiparesis. Bed mobility: the resident is dependent by times 2 staff to turn and reposition in bed. Record review of electronic progress notes dated 4/9/2026 06:15 a.m., revealed authored by LVN C CALLED BY CNAS UPON ENTERING RESIDENT ROOM, RESIDENT ON THE FLOOR ON HIS LEFT SIDE. CNAS WERE PROVIDING PATIENT CARE, WHEN RESIDENT GRABBED HIMSELF FROM MATTRESS AND ROLLED OVER TO THE RIGHT SIDE LANDING ON HIS RIGHT SIDE. ASSESSED RESIDENT HEAD TO TOE ASSESSMENT, LEFT LOWER SHOULDER BLADE SCRATCH, NO PAIN OR DISCOMFORT NOTED. NO BRUISING OR SKIN TEAR NOTED. Record review of Resident #1 x rays taken on 4/12/26 reflected: No evidence of a pneumothorax. No acute left rib fracture. During an interview on 4/28/26 ay 11:00 a.m., Resident #1 stated that one night he fell because there was supposed to be 2 CNAs and only one changed him. Resident #1 stated that he tried to grab from the mattress and when CNA E pulled the sheet he fell to the floor. Resident #1 stated that after 2 days the doctor ordered x rays. Resident #1 stated that the CNA E did not wait for the other CNA. LVN C was attempted to be contacted via telephone on 4/28/26 at 1:35 p.m., and 4/29/26 at 11:00 a.m., all attempts unsuccessful. CNA E was attempted to be contacted via telephone on 4/28/26 at 1:40 p.m., and 4/29/26 at 11:05 a.m., all attempts unsuccessful. During a phone interview on 4/28/26 at 1:42 p.m., CNA F said that she did know Resident #1 was a two person assist. CNA F said that she told CNA E to wait for her as she was giving assistance to another resident and CNA E decided to do the bed mobility by herself. CNA F said that if not following the plan of care, the resident pr herself could be harmed. During an interview on 4/28/26 at 1:55 p.m., LVN D stated Resident #1 required 2 person assist for bed mobility. LVN D stated that Resident #1 did not fall during her shift. LVN D stated that Resident #1 complained of pain to his right side of his trunk/back area on 4/10/26 and LVN D stated that she assessed Resident #1 and saw a discoloration on his left side of his trunk/back area about 5 inches long. LVN D stated that she asked the resident how it happened and he told her that he fell the day before. LVN D stated that she did not call the doctor because it was part of the fall incident from 4/9/26. During an interview on 4/29/26 at 5:53 p.m., the DON stated said staff should follow the plan of care of each resident to do the proper transfer. The DON said that both the resident and the staff could get injured if the failed to follow the plan of care. Record review of the facility policy titled, Incidents and Accidents, implemented date 8/15/22, revealed the following: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for change in condition. LVN D failed to identify a significant change in condition experienced by Resident #1 on 4/10/26. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.Finding included: Record review Resident #1's face sheet dated 04/28/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (complete paralysis and weakness on one side of the body are common, often debilitating, effects of a stroke). Record review of Resident #1's quarterly MDS assessment, dated 3/25/26 reflected BIMS(Brief Interview for Mental Status) score of 12, indicated cognition was moderate impaired. Section GG revealed Resident #1 was dependent for toileting hygiene (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan dated 12/24/24 reflected a focus area that Resident #1 had an ADL self-care performance deficit related to limited mobility, hemiplegia, hemiparesis. Bed mobility: the resident is dependent by times 2 staff to turn and reposition in bed. Record review of electronic progress notes dated 4/10/2026 07:50 p.m., revealed authored by LVN D REPORTED PER CNAS THAT WHILE CHANGING HIM THEY NOTICED DISCOLORATION TO LT LOWER BACK CLOSE TO ARM PIT, THIS NURSE CHECKED RESIDENT AND OBSERVED THAT HE HAD DRY SCRATCH LIKE AREAS TO LOWER BACK CLOSE TO ARM PIT WITH PURPLE DISCOLORATION AND RESIDENT STATED IT THIS HAPPENED BECAUSE I FELL YESTERDAY During an interview on 4/28/26 at 1:55 p.m., LVN D stated that Resident #1 complained of pain to his right side of trunk/back area on 4/10/26 and LVN D stated that she assessed Resident #1 and saw a discoloration on his left side of the trunk/back area about 5 inches long. LVN D stated that she asked resident how it happened and he told her that he fell the day before. LVN D stated that she did not called the doctor because it was part of the fall incident from 4/9/26. LVN D stated that she did not do a change in condition because she thought was a discoloration after the fall but the discoloration came out until the next day. During interview on 4/29/26 at 5:53 p.m., the DON stated that LVN D did not follow up with the doctor regarding the discoloration because it was part of the fall incident on 4/9/26. The DON stated LVN D did not have to follow up with the physician and that there was not a negative outcome. The DON stated that the change of condition or skin assessment was not done because it was part of the fall from 4/9/26. Record review of the facility policy titled, Notification of Changes implemented date 10/24/22, revealed the following: It is the purpose of this policy is to ensure that the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #2) of 7 residents reviewed for Advance Directives. The facility failed to ensure Resident #2's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature for Resident #2. This failure could affect all residents who have implemented advance directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #2's electronic face sheet dated 03/24/2026 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: nontraumatic intracerebral hemorrhage in the cortical hemisphere (a spontaneous bleeding event not caused by injury within the brain's superficial gray matter), other toxic encephalopathy (a brain dysfunction resulting from exposure to hazardous substances like industrial chemicals, heavy metals, solvents or medication), pneumonia due to inhalation of food and vomit, and Wernicke's encephalopathy (a life-threatening, acute neurological emergency caused by severe deficiency of vitamin B1. Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 09 which reflected moderate cognitive impairment. Resident #2 had unclear speech, was sometimes understood by others and sometimes understood others. Record review of Resident #2's comprehensive care plan dated 03/19/2026 reflected, Resident #2's FOCUS: Resident #2 [sic] is a DNR. Date Initiated: 02/05/2026 Revision on: 02/05/2026. Record review of Resident #2's Progress Note dated 02/04/2026 at 11:29 am reflected, a SS note concerning the quarterly care plan meeting RP wants to switch from Full code status to DNR. Record review of Resident #2's order summary dated 03/25/2026 reflected a DNR order dated 02/04/2026. Record review of Resident #2's OOH-DNR dated 02/04/2026 reflected the RP and two witness's signatures. The OOH-DNR did not have a physician's signature. During an interview on 03/24/2026 at 03:41 pm, SS A stated the DNR for Resident #2 had not been signed by the physician. She said she considered it valid due to the RP requesting the resident's code status be changed from full code to DNR. She said she did not know why the physician had not signed the DNR form yet, but the RP and witnesses had signed it on 02/04/2026. She said if anything happened in the facility, the DNR would be honored even though the physician had not signed it. During an interview on 03/24/2026 at 03:50 pm, the DON stated there was not a physician's signature on Resident #2's OOH-DNR that was signed by the RP and two witnesses on 02/04/2026, but it would be honored if anything would happen to Resident #2 while at the facility. She said they had sent Resident #2's OOH-DNR to the doctor, but he had not signed it. She said there was an order for the OOH-DNR. During an interview on 03/24/2026 at 04:30 pm, the Administrator stated they had already contacted the doctor about signing Resident #2's OOH-DNR. She said he had already signed it and sent it back. She said they had already uploaded it into PCC. She said if the RP requested and signed a OOH-DNR and there were two witnesses, but the physician had not signed, the OOH-DNR would be honored in-house if something would occur. Record review of the facility's Residents' Rights Regarding Treatment and Advanced Directives policy dated 10/24/2022, revealed: Policy:It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical and surgical treatment and to formulate an advance directive.Policy Explanation and Compliance Guidelines:1.On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. 3.Upon admission, should the resident have an advance directive, copies will be made and placed in the chart as well as communicated to the staff. Record review of the 02/04/2026 OOH DNR Order instructions for issuing and OOH-DNR Order revealed the Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity.Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document the existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: .In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 (Resident #1 and Resident #3) of 7 residents reviewed for medical records accuracy, in that: 1.The facility failed to provide physician or NP documentation in the electronic medical record for Resident #1 from 01/01/2026 through 03/24/2026. 1.The facility failed to provide physician or NP documentation in the electronic medical record for Resident #3 from 02/21/2026 through 03/24/2026. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.The findings included: 1.Record review of Resident #1's electronic face sheet dated 03/23/2026 reflected the resident was a [AGE] year-old male who had an initial admission on [DATE] and was readmitted to the facility on [DATE]. His diagnoses included: Cerebral infarction (stroke) affecting right dominant side, Parkinson's disease (a neurodegenerative disorder where brain cells that produce dopamine die, causing motor issues like tremors, stiffness, and slowness, alongside non-motor symptoms like smell loss, constipation, and depression), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks), end stage renal disease (the kidneys can no longer filter waste and fluids effectively), dependence on kidney dialysis, and Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar to build up in the blood instead of entering cells for energy Record review of Resident #1's Medicare 5-Day MDS assessment dated [DATE] reflected a blank BIMS score which reflected Resident #1's interview was not completed or attempted. Resident #1 had no speech, was rarely/never understood by others and rarely/never understood others. Resident #1 was dependent (helper did all of the effort. The resident did none of the effort to complete the activity or, the assistance of 2 or more helpers was required for the resident to complete the activity) for toileting, showering, and personal hygiene. The resident was always incontinent of bladder and bowels. Record review of Resident #1's Progress Note dated 01/30/2026 at 11:13 am by LVN C revealed FNP D was in the facility to assess Resident #1 and medication changes were ordered. Record review of Resident #1's Progress Note dated 02/03/2026 at 11:15 am written by LVN C revealed FNP C was in the facility assessing Resident #1. FNP D ordered a new medication. LVN C documented that FNP D would follow-up with Resident #1 when she rounded on 02/06/2026. Record review of Resident #1's Progress Note dated 02/20/2026 at 11:23 am written by LVN C revealed FNP C was in the facility to assess Resident #1 and medication changes were made. Record review of Resident #1's Progress Note dated 03/17/2026 at 02:03 pm written by LVN E revealed Resident #1 was seen by FNP F and to notify her if lab values were critical in the morning. Record review of Resident #1's Progress Notes and Miscellaneous section revealed there was no documentation written by the physician or NP from 01/21/2026 through 03/24/2026. 2. Record review of Resident #3's electronic face sheet dated 03/23/26 reflected the resident was a [AGE] year-old female who had an initial admission on [DATE] and was readmitted to the facility on [DATE]. Her diagnoses included: Hypertension (high blood pressure), Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar to build up in the blood instead of entering cells for energy), heart disease, and other toxic encephalopathy (a brain dysfunction resulting from exposure to hazardous substances like industrial chemicals, heavy metals, solvents or medication) Record review of Resident #3's Medicare 5-Day MDS assessment dated [DATE] reflected a BIMS score of 09 which reflected moderate cognitive impairment. Resident #3 had clear speech, was usually understood by others and usually understood others. Resident #3 required substantial/maximal assistance (Helper did MORE THAN HALF the effort. The helper lifted or held resident's trunk or limbs and provided more than half the effort dependent) for toileting and showering. The resident was frequently incontinent of her bladder and occasionally incontinent of her bowels. Record review of Resident #3's Progress Note dated 02/23/2026 at 08:13 pm written by LVN G revealed NP H was in the facility and was notified of Resident #3's high blood sugar (number not documented in note). NP H was also notified of the family's request to review Resident #3's medications and to discontinue some of the medications. LVN G wrote, and he did. Record review of Resident #3's Progress Notes and Miscellaneous revealed there was no documentation written by the physician or NP from 02/21/2026 through 03/24/2026. During an interview on 03/24/2026 at 03:50 pm, the DON stated the doctors and NPs should have notes in the Progress Notes or Miscellaneous on PCC. She said they wrote their notes on paper and then the notes were uploaded into the Miscellaneous tab on PCC. The DON stated she did not know why Resident #1's and Resident #3's charts had no doctor or NP notes in PCC. She said she would talk to the doctor. She said if the doctors or NPs' notes were not in the computer, it would not show a resident's progress or status. During an interview on 03/24/2026 at 04:30 pm, the Administrator stated there should be notes from the doctors and NPs in PCC. She said they were always on their computers when they were at the facility. She said she would talk to the NP's doctor to ensure notes were being put in PCC for every visit they made. She said there were some NPs who came three days a week. She said she did not know how or why there were no doctor or NP notes in PCC for Resident #1 or Resident #3. Record review of the facility's Documentation in Medical Record policy dated 10/24/2022, revealed: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines:1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (400 hallway) of 5 medication carts. The facility failed to ensure that the nurses medication cart for the 400 hall was secured by a lock when it was left unattended by GVN A. These failures could place residents at risk of injury to other residents if medication left unsecured were consumed.Findings included: During an observation on 2/18/2026 at 06:07 PM revealed the 400 Hall nurse's medication cart was left unlocked and unattended against the nurse's station. During the observation GVN A was called by surveyor and informed her that the medication cart was unlocked. GVN A secured the cart by locking it. During an interview on 2/18/2026 at 06:07 PM with GVN A revealed he was responsible for the nurse's medication cart that was left unlocked. He stated he was expected to lock the nurse's medication cart when he walked away from it. He said that inside the cart there was medications of the residents for 400 hallway. He stated if it was left unlocked then a resident could open a drawer and take a medication that was not for them. During an interview on 2/18/2026 at 06:13 PM with the DON revealed numerous staff, including she and the ADON, were responsible for ensuring medications carts were locked. The DON stated his expectation of staff when they walked away from the medication cart was to lock it. The DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. Record review of undated facility policy Medication Carts and Supplies for Administering Meds dated 10/1/2019 revealed The medication cart is locked at all times when not in use

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts (300 Hall Nurse Cart, Blue Med-Aide Cart, and 200 Hall Nurse Cart) reviewed for labeling and storage.The facility failed to ensure the 300 Hall Nurse Cart belonging to LVN-E was free from personal items.The facility failed to ensure the Blue Med-Aide Cart belonging to Medication Aide-D was free from medications without labels. The facility also failed to ensure the 200 Hall Nurse Cart belonging to LVN-C was locked and secured.These failures could place residents at risk of being administered a wrong or possibly expired medication, a medication which could have been exposed to cross-contamination, as well as a risk of residents gaining access to unlocked medications which were not prescribed to them and could cause them harm.The findings included:An observation on 01/14/2026 at 10:41 AM of the 300 Hall Nurse Cart revealed a white personalized bag which contained a toothbrush, toothpaste, dental floss, and body spray. An observation on 01/14/2026 at 11:14 AM of the Blue Med-Aide Cart revealed a brown prescription bottle approximately 3/4 of the way full of a liquid. The prescription on the label was so faded it could not be read what the medication was, when it expired, or which resident it belonged to. An observation on 01/14/2026 at 9:04 PM of the 200 Hall Nurse Cart revealed an unlocked medication cart. The lock on the cart was popped out, and all drawers except the narcotic drawer were able to be accessed. In an interview on 01/14/2026 at 10:05 PM, LVN-C stated she knew she was not supposed to leave her med-cart unlocked when she walked away. She stated she had never done this in the past, so she was not sure why it happened tonight, other than she was busy with the residents. LVN-C stated if a med-cart was left unlocked residents could have gotten into the cart and taken medications which had not belonged to them, which could have caused them harm. LVN-C stated she had been in-serviced on this before, but she could not recall how long ago the in-service was.In an interview on 01/14/2026 at 10:42 AM, LVN-E stated she believed the bag belonged to one of the nurses because she had seen it in the 300 Hall Nurse Cart before, but she had no idea which nurse it belonged to. LVN-E stated personal belongings did not belong in the medication carts because they could have caused cross-contamination with the medication and could have possibly caused harm to the residents. In an interview on 01/14/2026 at 11:16 AM, Medication Aide-D stated she was not sure where the bottle of liquid medication on the Blue Med-Cart came from, and she was not sure which resident it belonged to since she was unable to read the label. She stated this medication could be a risk to residents' health because if it was administered to the wrong resident, or if it had expired or gone bad, it could make the resident sick. She stated she had never given this medication before.In an interview on 01/14/2026 at 11:24 AM, ADON-B stated nurses were not supposed to leave personal belongings in the medication carts because it could have caused a cross contamination with residents' medication and caused them to be sick. She also stated nurses should have checked the medication carts each shift for expired medications and notified the ADON or DON if they had expired medications. ADON-B stated if a resident was given a medication without a legible label on it, they could have gotten the wrong medication or an expired medication which could have caused them harm. In an interview on 01/15/2025 at 9:00 AM, the DON stated nurses routinely checked their medication carts for expired medications, as well as the pharmacist typically checked them at least monthly while at the facility. She also stated nurses should not leave their medication carts unlocked because residents could have gained access to medications which did not belong to them, and this could have caused the residents harm. Record review of the facility's Medication Administration policy, dated 10/24/2022, revealed 1. Keep medication cart clean, organized, and stocked with adequate supplies. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. 12. Identify expiration date. If expired, notify nurse manager.Record review of the facility's Medication Carts and Supplies for Administering Meds policy, dated 10/01/2019, revealed 2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas. 10. Equipment and supplies relating to medication administration are clean and orderly.

Based on observation, interviews and record review, the facility failed to store, distribute and sever food in accordance with professional standards for food service safety for 1 of 2 refrigerators (1 of 2 kitchen refrigerator) and 3 of the 3 steam table wells reviewed for storage, preparation, and sanitation. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was labeled and dated. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was sealed properly. -The facility failed to ensure a box of cabbage in the kitchen refrigerator was not expired and spoiled. -The facility failed to ensure 3 of 3 the steam table wells were cleaned. -These failures could place residents at risk of complications from food contamination. Findings included: Observations during the initial tour of the kitchen on 01/13/26 at 9:36 a.m. revealed a box in the refrigerator with eight heads of cabbage spoiled and had black mold and did not have use by date. Observation of 3 of 3 steam table wells revealed white build up on the bottom 3 of 3 steam wells observed. In an interview on 01/14/25 at 9:15 a.m. with DA G she stated the steam table wells were cleaned every day by all staff at all shifts after every use. DA G stated she did not know why they were in the condition they were in but she cleaned it after every use during her shift. DA G stated it was important to keep the steam table well clean and working good so the food is served at the right temperature so no bacteria could be present. DA G stated she did not know of the cabbage in the refrigerator but knows all food stored in refrigerator was to be labeled dated and covered. In an interview with the DM on 01/14/26 at 9:43 a.m. stated she and the staff clean out the refrigerator daily and the cabbage in the box were not stored correctly. The DM stated they should have placed with a protective barrier with an in date of when it was placed in the refrigerator. The DM said the cabbage had not been used for cooking, and that could be why the cabbage was not noticed with no use by date and had begun to spoil. The DM stated she did not know why they did not have a date on the box with the cabbage or when the cabbage was put in the refrigerator as all other items had a date on the containers. The DM stated she will do retraining on the importance or maintaining the steam tables clean and in good working condition so the food is maintained at the correct temperature to ensure residents don't get sick from the food being contaminated bacteria and with dating items and making sure they are all covered and not exposed to the air with containers sealed correctly and throwing out all expired foods for all forms of storage. Record review of the facility's policy dated 2018, titled, Food Storage revealed to ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, Ready-to eat, Time/Temperature Control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, record review, and interview, 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 one of six Residents (Resident #88) that were reviewed for infection control and transmission-based precautions policies and practices. The facility failed to ensure the WCN performed hand hygiene after removing gloves while prepping Resident #88's supplies for wound care. This failure could place residents at risk of infection through cross contamination of pathogens and infectious diseases. Findings include: Record review of Resident #88's face sheet dated 01/14/26 reflected an [AGE] year-old-female with an original admission date of 12/29/25. Diagnoses included hypotension (low blood pressure), end stage renal (kidney) disease, and type 2 diabetes (insufficient insulin production in the body). Record review of Resident #88's admissions MDS dated [DATE] reflected a BIMS score of 12 (cognition moderately impaired). Record review of Resident #88's physician's orders reflected:1. tx to coccyx, one time a day for unstageable (severe type of wound where the depth cannot be determined due to the presence of slough or eschar) pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time); cleanse with wound cleanser, pat dry, apply betadine (antiseptic solution used to promote healing to wounds) cast and cover with dry dressing qd till resolved. Dated 01/05/2026. 2. tx to right heel, pressure ulcer unstageable; cleanse with wound cleanser, pat dry, apply betadine cast and cover with dry dressing qd till resolved. Dated 01/05/2026. 3. tx to right ear, pressure ulcer stage 1 (injury of intact skin with the presence of non-blanchable redness); cleanse with wound cleanser, pat dry, apply betadine cast and cover with dry dressing qd till resolved. Dated 01/05/2026. During a wound care observation of Resident #88 on 01/14/26 at 1:15 PM, the WCN was preparing the supplies needed and disinfected the scissors. The WCN then removed her gloves and did not perform hand hygiene prior to putting on new gloves. In an interview on 01/14/26 at 1:59 PM, the WCN stated she did not realize she did not perform hand hygiene after sanitizing the scissors. The WCN stated she was nervous and just forgot. The WCN stated it was important to perform hand hygiene after glove removal to prevent cross contamination and because the scissors were dirty and had Clorox on them from the Clorox wipe used. The WCN stated if Resident #88's wounds came into contact with bacteria; the wound could become infected or worse. In an interview on 01/14/26 at 9:44 PM, the DON stated all staff should be performing hand hygiene after every glove removal to prevent the spread of infection. The DON stated if Resident #88's wound came in contact with any bacteria; the wound could become infected, worsen or delay healing. Record review of the facilities Hand Hygiene policy dated 10/24/22 reflected: Policy: All staff will perform hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub. 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of six residents (Resident #23) reviewed for medication errors. The facility failed to ensure Resident #23's blood pressure/pulse altering medications (Amlodipine) was not given outside of the blood pressure parameters during the month of December 2025 per the physician's orders. This failure could place residents at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease processes, and potential hospitalization. Findings include: Record review of Resident #23's face sheet dated 01/14/26 reflected a [AGE] year-old-male with an original admission date of 10/28/24. Diagnoses included type 2 diabetes (insufficient insulin production in the body), Parkinsons disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), Alzheimer's disease (progressive mental deterioration of the brain affecting memory, thinking and behavior), hypertensive urgency (severe high blood pressure), and end stage renal (kidney) disease. Record review of Resident #23's physician's orders dated 11/25/25 reflected:Amlodipine Oral Tablet 10 MG. Give 1 tablet via G-Tube one time a day for HTN, hold for BP<100/60, HR <60. Record review of Resident #23's quarterly MDS dated [DATE] reflected a BIMS of 00 which indicated severe cognitive impairment. Record review of Resident #23's December 2025 MAR blood pressure and pulse summaries reflected the following:On 12/04/25, Resident #23's blood pressure was 130/53 with a pulse of 92. RN F documented in the MAR, the medication of Amlodipine was given. On 12/22/25. Resident #23's blood pressure was 135/51 with a pulse of 81. RN F documented in the MAR, the medication of Amlodipine was given. On 12/23/25, Resident #23's blood pressure was 131/57 with a pulse of 100. RN F documented in the MAR, the medication of Amlodipine was given. In an interview on 01/15/2026 at 8:48 AM, RN F stated according to the physician's orders, Resident #23's medication of Amlodipine should have been held since the diastolic blood pressure was less than 60. RN F stated he knew when the medication should have been held and if the medication was given, then it was a typing error. RN F stated all three entries were made in error because he has big fingers and a mistake could have been made. RN F stated if the medication was given outside of parameters, Resident #23's blood pressure could have dropped low, and the resident could have experienced dizziness or fainting. In an interview on 01/15/2026 at 9:59 AM, the DON stated Resident #23's blood pressure medication should not have been given since the blood pressure was outside of parameters per physician's orders. The DON stated if the medication was given outside of parameters, Resident #23's blood pressure could drop, and resident could have had dizziness and possible blurred vision. Record review of the facility's Medication Administration policy dated 10/24/22 reflected; Policy Explanation and Compliance Guidelines 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's parameters.

Based on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the culture and ethnic needs of the resident population in accordance with established national guidelines for all residents when the facility failed to ensure menus were accommodated for all residents for 1 of 3 meals observed. The facility failed to reflect, based on a facility's reasonable efforts, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups.This failure could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.The findings included: In observation and interview of the Resident council meeting on 01/14/26 at 2:30 pm revealed the all the residents who attended the meeting were not happy with the selection they were served daily. The attendees stated they did not like some of the items served on the menu and wanted more foods that they enjoyed from their Mexican culture. The president of the Resident Council, R #99, stated he could speak for all residents in the facility who have told him the menu did not offer them enough Mexican style foods in the menu and tended to serve food the Mexican residents were not accustomed to eating. In record review on 01/14/25 at 5:00 p.m. of the Mexican/ Hispanic menu only one day of the 4 weeks of the menu had one day that served Mexican style entrees of lunch Pork Carne Guisada (stewed pork in gravy) roasted potatoes winter vegetable mix corn tortilla, and dinner Chicken fajitas(grilled chicken with peppers) , Mexican Rice, sauteed peppers and corn tortilla. The other days the facility offered Shepherd's pie, smoked ham, chicken Dijon, tuna patty, spaghetti with meatballs, deli sandwich, sweet and sour chicken, pepperoni pizza, fried fish, BBQ pork and meatballs with buttered noodles and broccoli cheese soup or chicken salad sandwich. In an interview on 01/15/26 at 9:30 am with the Dietary Manager she stated the menus are changed every 5 weeks and she is responsible for making any changes in the menu if a certain type of food on the menu is not being eaten by the residents. The menu was on a 5-week rotation and has two menus a seasonal and a Mex/Hispanic menu. The DM stated she was given resident food preferences updated in the quarterly assessment of the resident. The DM stated it was very important the residents to receive food that was liked and healthy so there was no big or rapid weight loss or gain. The DM said she would swap out all the items she sees which are not liked and eaten by the residents for a more cultural healthy substitute. The DM stated the menus come from a distributor of food products, and that was what they followed, but will look for other types of menus and would make changes and add different kinds of Mexican food to the rotation of the menus. The DM stated breakfast was a challenge breakfast was more individualized but will see if adding salsa to the menu would make the breakfast more edible and not so bland and boring. The DM will make sure to the residents' choices are met in a healthy way, monitor which types of food come back uneaten and will make changes to all menus and snacks. In an interview 01/15/26 at 10:30AM with Dietitian he stated the DM was given the food preferences and updated quarterly in the assessment. The DM stated if the resident is identified to not eat often a shake or alternative is given to ensure the resident is having an intake of food and nutrition. Two cycle menus only change every other month and they are on a 5-week cycle menu. The dietitian would change food items if certain foods don't work and meet dietary requirements with the residents. The dietitian stated the DM will swap out items if needed if residents don't eat before he is able to make changes. The menu comes from the distributor, and the menu is either a seasonal or regular menu. The daily intake is different at every meal for protein and vegetables and fruits and is adjusted. The dietitian stated breakfast was more individual and health based so not to many changes can occur. The dietary manger is responsible for the changes in menu when the resident is assessed and changes need to be made. The dietitian stated the CNA's are responsible for meal intakes and percentage documentation for the residents. The dietitian stated he tries to make it to the facility once a week to go over any issues with resident diets and menus that need to be updated for nutritional value with any changes. Record review of facility kitchen policies titled Food and Nutrition Services revised Policy dated 6/1/19 reveal The facility believes that nutrition is an important part of maintaining the wellbeing and health of its residents and is committed to providing a menu that is well balanced, nutritious and meets the preferences of the resident population. A standardized menu which meets the nutritional recommendations of the residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences will be used. Modifications for resident population and preferences may be made as appropriate.

Based on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 12 residents' reviewed for residents' rights.The facility failed to ensure CMA A locked the medication cart computer screen and left an unidentified resident's picture exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. The findings include:Observation and interview on 9/16/25 at 3:40 p.m. revealed CMA A walked out of a resident room from across the hall on the 400 hall and walked up to the unlocked computer screen on top of the medication cart counter which exposed a resident's picture. CMA A stated, she forgot to lock the computer screen and left the computer screen open which was a HIPAA violation and could result in an unauthorized person obtaining information from the resident and using their name fraudulently. During an interview on 9/16/25 at 5:40 p.m., the DON stated it was her expectation that staff locked the computer screens because exposed resident information was a HIPAA violation. The DON stated a resident's visible information could be used in the wrong way. Record review of the facility's document titled, Resident Rights, with revision date November 2021, revealed in part, .You have the right to: privacy, including during visits, phone calls and while attending to personal needs. Have facility information about you maintained as confidential

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 2 reviewed for accuracy and completeness of clinical records. The facility failed to accurately document in Resident #1's electronic medical record when she had her staples removed. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health. Findings include: Record review of Resident #1's admission record dated 09/17/25 reflected an [AGE] year-old female with an admit date of 09/12/24 and a discharge date of 10/01/24. Her relevant diagnoses included left arm displaced comminuted (the pieces of the bone moved so much that a gap formed around the fracture) fracture of shaft of ulna(the long, tapering portion of the ulna bone), left arm displaced comminuted fracture of left humerus (long bone that runs from the shoulder and scapula), fracture of left pubis (one of the three bones that make up the hip bone), age-related physical debility (decline in strength and vitality associated with aging), and a commuted distal ulnar/radial fracture, left humeral shaft fracture, and left interior ramus fracture. Record review of Resident #1's Medicare 5-day MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated her cognition was moderately impaired. Resident #1 had fractures and other multiple traumas as active diagnoses prior to being admitted . Record review of Resident #1's initial care plan dated 09/16/24 reflected: Problem: Resident #1 had an alteration in musculoskeletal status related to ulna/radius/humerus fracture, left pubis fracture. Interventions: in part included wearing a sling to the upper left extremity as per MD orders. Record review of Resident #1's progress note, dated 09/12/24 at 4:10 pm, authored by LVN B reflected in part [Resident #1] had been admitted from hospital . [Resident #1] was admitted to hospital related to a trip/fall at home in which she sustained a commuted distal ulnar/radial fracture, left humeral shaft fracture, left interior ramus fracture. [Resident #1] had left upper arm surgical wound with 30 staples, left wrist surgical wound with 12 staples. Record review of Resident #1's electronic medical record for the month of September 2024 reflected an entry on 09/23/24 which reflected: As per Dr., may remove staples from left surgical site. Start date 09/23/24. Order was signed off on 09/23/24 at 6:13 pm.Record review of Resident #1's progress note dated 09/30/24 at 4:49 pm, authored by LVN B reflected received orders from doctor, as per doctor may discontinue staples to left arm in facility. [Resident #1] and resident family made aware. In a telephone interview on 09/18/25 at 9:30 am, RN B said he remembered he entered an order to remove Resident #1's staples on 09/30/24 towards the end of his shift. RN B said he did not remember if he was the one who removed Resident #1's staples. In an interview on 09/18/25 at 10:00 am, LVN C said she received an order for Resident #1 on 09/23/24 to remove staples from the left surgical site. LVN C said she did not remember removing the staples herself and did not know who removed them. During a telephone interview on 09/18/25 at 10:37 am, Resident #1's RP said she had witnessed Resident #1's staples being removed on 09/23/24, by male nurse (did not get his name). Resident #1's RP said her mother had tolerated the removal and did not required medication. In an interview on 09/18/25 at 10:08 am, The DON said the facility's protocol for removing staples was to first obtain an order and then prepare the resident for the actual removal. The DON said after the removal, the nursing staff who removed the staples was required to enter a progress note that indicated whether the resident had tolerated the removal, if any significant findings were noted, the number of staples removed, and if any staples were left. The DON said the facility received two separate orders to remove Resident #1's staples, one on 09/23/24 and a second one on 09/30/24. She said she was not sure why they had received two. The DON said she was certain Resident #1's staples were removed on 09/23/24 as it was signed off on her electronic medical record. She said who signed off on the removal was the wound care nurse at that time and was no longer working at the facility. She said she could not explain why a second order was received on 09/30/24 and the documentation dated 09/30/24 was vague. The DON said the previous wound care nurse who removed Resident #1's staples had not documented the required information in Resident #1's electronic medical record. She said there were no negative outcomes to Resident #1 as her staples were removed on 09/23/24. This surveyor requested the facility's previous wound care nurse phone number but was not provided.Record review on 09/18/25 of Resident #1's electronic medical record reflected the previous wound care nurse had not documented she had removed Resident #1's staples. Record review of the facility's Documentation in the Medical Record policy dated 10/24/22 reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #2), reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #2's physician ordered Cozaar was held when her blood pressure was found to be out of parameters for administration. This failure could place residents at risk for not receiving medication as ordered. The findings included: 1. Record review of Resident #2's face sheet, dated 04/29/25, revealed the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: other acute (sudden) kidney failure, secondary malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct, and secondary malignant neoplasm of retroperitoneum (is the space behind the peritoneum) and peritoneum (membrane that lines the abdominal cavity and covers the abdominal organs), essential (primary) hypertension (high blood pressure). Record review of Resident #2's MDS assessment, dated 04/22/25, revealed Resident #2 had a BIMS score of 10, indicating her cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/21/25 reflected, [Resident #2] has altered cardiovascular status r/t (related to) CHF (congestive heart failure), hypertension with an initiation date of 05/02/25 with a goal of, The resident will be free from complications of cardiac problems through review date. with an initiation date of 05/02/25. Record review of Resident #2's physician's orders revealed orders for Cozaar Oral Tablet 50 MG, with additional directions of HOLD IF SBP (systolic blood pressure) <120 AND/OR DBP (diastolic blood pressure) <60 HOLD IF PULSE IS <60 with a start date of 04/18/25. Record review of Resident #2's April 2025 MAR revealed, Resident #2's physician order for, Cozaar Oral Tablet 50MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN (hypertension) HOLD IF SBP is <120 AND/OR DBP <60 HOLD IF PULSE IS <60 was administered on 04/19/25, 04/20/25 and 04/21/25 based on check offs and signatures completed by MA A, MA B and MA C while Resident #2's blood pressure was out of parameters for administration of medication. On 04/19/25 Resident #2 had a blood pressure of 106/60, on 04/20/25 Resident #2 had a blood pressure of 114/68 and on 04/21/25 Resident #2 had a blood pressure of 106/71. During an interview with MA C on 04/25/25 at 4:58pm she stated she worked with Resident #2 on 04/21/25 and was responsible for administering Resident #2's medication. MA C stated prior to administering Cozaar she needed to check both blood pressure and pulse in the order to see if they would receive the medication or not. MA C stated on 04/21/25 she checked Resident #2's blood pressure and stated it was out of parameters and was at 106/71 from what she could recall. MA C stated she did not know provide Resident #2 with Cozaar and held it and stated her blood pressure was not within parameters. MA C stated she signed the MAR as administered by mistake and stated she did not notify any nurse about Resident #2's blood pressure being out of parameters and medication being held and stated she should have notified the nurse. MA C did not recall who the overnight nurse was. MA C stated she had received in-services over signing the MAR. During a follow up interview with MA C on 05/13/25 at 2:55pm MA C stated she would have to go to her DON for what the facility policy stated over accurately documenting on the MAR. MA C stated incorrect documentation could negatively impact them really bad and stated she did not know what to answer. During an interview with MA B on 04/29/25 at 2:42pm she stated she worked with Resident #2 on 04/20/25 and was responsible for administering Resident #2's medication. MA B stated prior to administering Cozaar she needed to look at the parameters, MA B stated she checked Resident #2's blood pressure and it was 114/68 and stated based on that reading it should not have been administered. MA B stated she assumed the parameters for Resident #2 were the same as before because they never had parameters like Resident #2's at the facility before. MA B stated the blood pressure parameters at the facility were all almost the same and were usually 100/60 and stated this one kind of slipped on us and she stated after she took Resident #2's blood pressure she gave her the Cozaar medication and Resident #2 spit it out due to being nauseous. MA B stated that because she had placed the medication in Residents #2's mouth she documented it as administered. MA B stated she could have written a note about the administered and spit out medication but did not, MA B stated she probably just forgot to write a note because they were busy most of the time. MA B stated she thought she had told a nurse about Resident #2 being administered her Cozaar and then spitting it out but could not remember. MA B stated she had received in-services over signing the MAR and following the parameters after the incident had occurred. MA B stated the facility policy for medication parameters stated to always take the blood pressure before administering. MA B stated she had not followed the facility policy due to not reading the parameters. MA B stated it was important to review orders, parameters, and directions prior to administering medication because it was procedure and important for the resident safety. MA B stated providing blood pressure mediation to a resident who was not within parameters could be negatively impacted because their blood pressure could go down. During an interview with MA A on 05/13/25 at 8:57am she stated she worked with Resident #2 on 04/19/25 and was responsible for administering Resident #2's medication. MA A stated prior to administering Cozaar she needed to see how the patient was and check their blood pressure and compare it to the parameters listed on the order to see if they would receive the medication or not. MA A stated on 04/19/25 she checked Resident #2's blood pressure but did not recall the exact reading and stated she thought it was 100 or 114 over 70. MA A was shown Resident #2's April 2025 MAR that revealed a blood pressure of 106/62, MA A stated based on the blood pressure her Cozaar should not be administered. MA A stated she did not administer Cozaar to Resident #2 on 04/19/25 and stated she should have coded it as 4 which she stated indicated the resident was out of parameters and the medication could not be given. MA A stated she did not know why she signed it as administered and stated she was just in a rush. MA A stated she should have notified the nurse that the Resident #2's blood pressure was out of parameters and that the medication would be held, MA A did not remember if she notified the nurse. MA A stated she had received in-services over signing the MAR. MA A stated she did not recall seeing a facility policy over accurately documenting on the MAR. MA A stated incorrect documentation could negatively impact a resident's health. During an interview with the DON on 05/13/25 at 5:29pm she stated MA A was responsible for administration and documentation on the MAR for Resident #2's Cozaar on 04/19/25, MA B was responsible on 04/20/25 and MA A on 04/21/25. The DON stated the staff had to check the blood pressure and pulse prior to administering and stated a blood pressure under 120/60 or a pulse under 60 would require the medication to be held. The DON stated all 3 staff members checked Resident #2's blood pressure and stated her Cozaar should not have been administered on any of the 3 days based on her blood pressure of 106/62 on 04/19/25, 114/68 on 04/20/25 and 106/71 on 04/21/25. The DON reviewed Resident #2's April 2025 MAR and confirmed the blood pressure of 106/62 on 04/19/25, 114/68 on 04/20/25 and 106/71 on 04/21/25. The DON stated MA A and C did not administer the medication on 04/19/25 and 04/25. The DON stated MA A and MA C signed as administered in error and stated it should have been coded as out of parameters. The DON stated MA B gave the medication to Resident #2 but she spit it out. The DON stated she did not know why MA B administered Cozaar to Resident #2 when she had her blood pressure out of parameters and stated it was a mistake she overlooked. The DON stated staff had been trained to check the blood pressure, look at the parameters and to notify the nurse if out of parameters and to document if given or not. The DON stated MA B could have written a note and should have documented it as not administered and should have notified the nurse of the blood pressure being out of parameters and being held. The DON stated in all 3 situation the staff should have notified the nurses and stated they had not based on what she knew. The DON stated all 3 staff had been trained on signing the MAR and following medication parameters. The DON stated all 3 staff were trained immediately after and prior but could not recall when. The DON stated the facility policy for following parameters for medication stated they were responsible for following physician orders. The DON stated the 3 staff did not follow the facility policies. The DON stated incorrect documentation on the MAR could negatively impact the resident because it reflected something was provided when it was not. The DON stated providing blood pressure medication to a resident whose blood pressure was not in parameter could negatively impact them on a case by case basis and could lower the blood pressure. The DON stated she determined staff were competent to provide residents medication while following the order in place by doing medication pass audits, training, and competencies. The DON stated all 3 staff have completed competencies for order, parameters and documentation. Record review of Medication Pass Competency Assessment dated 07/03/24 for MA A, MA B and MA C reflected they were checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/28/25 for MA A, reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/29/25 for MA B reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/30/25 for MA C reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review on facility Inservice dated 04/21/25 that covered topic of FOLLOW MD ORDERS AND PARAMETER FOR MEDICATION ADMINISTRATION with a summary of, CMAS AND CHARGE NURSES SHOULD FOLOW THE MD ORDERS WHEN ADMINISTER [administering] MEDICATIONS AS WELL AS MEDICATION ADMINISTRATION PARAMETERS. CMAS SHOULD NOTIFY CHARGE NURSE WHEN HOLDING MEDCIATION AND WHEN RESIDENT REFUSE MEDICATION CHARGE NURSE TO NOTIFY MD OF MEDICAITON REFUSALS AND WHEN MEDICZTIONS ARE HELD. Revealed MA A, MA B and MA C had all received the education. Record review of employee counseling report dated 04/21/25 revealed MA C had documented the administration of medication however no medication was required or administered per the residents' parameters. Record review of facility policy titled Medication Administration with an implementation date of 10/24/22 stated, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside of the physician prescribed parameters. and 19. Report and document any adverse side effects or refusals. And 20. Correct any discrepancies and report to nurse manager.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's April 2025 MAR documentation was inaccurate. Staff signed off on physician ordered medication as administered when it was not. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. The findings included: 1. Record review of Resident #2's face sheet, dated 04/29/25, revealed the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: other acute (sudden) kidney failure, secondary malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct, and secondary malignant neoplasm of retroperitoneum (is the space behind the peritoneum) and peritoneum (membrane that lines the abdominal cavity and covers the abdominal organs), essential (primary) hypertension (high blood pressure). Record review of Resident #2's MDS assessment, dated 04/22/25, revealed Resident #2 had a BIMS score of 10, indicating her cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/21/25 reflected, [Resident #2] has altered cardiovascular status r/t (related to) CHF (congestive heart failure), hypertension with an initiation date of 05/02/25 with a goal of, The resident will be free from complications of cardiac problems through review date. with an initiation date of 05/02/25. Record review of Resident #2's physician's orders revealed orders for Cozaar Oral Tablet 50 MG, with additional directions of HOLD IF SBP (systolic blood pressure) <120 AND/OR DBP (diastolic blood pressure) <60 HOLD IF PULSE IS <60 with a start date of 04/18/25. Record review of Resident #2's April 2025 MAR revealed, Resident #2's physician order for, Cozaar Oral Tablet 50MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN (hypertension) HOLD IF SBP is <120 AND/OR DBP <60 HOLD IF PULSE IS <60 was administered on 04/19/25 by MA A, 04/20/25 by MA B and 04/21/25 by MA C based on check offs and signatures completed by MA A, MA B and MA C while Resident #2's blood pressure was out of parameters for administration of medication. On 04/19/25 Resident #2 had a blood pressure of 106/60, on 04/20/25 Resident #2 had a blood pressure of 114/68 and on 04/21/25 Resident #2 had a blood pressure of 106/71. During an interview with MA C on 04/25/25 at 4:58pm she stated she worked with Resident #2 on 04/21/25 and was responsible for administering Resident #2's medication. MA C stated prior to administering Cozaar she needed to check both blood pressure and pulse in the order to see if they would receive the medication or not. MA C stated on 04/21/25 she checked Resident #2's blood pressure and stated it was out of parameters and was at 106/71 from what she could recall. MA C stated Resident #2's blood pressure was not within parameters and stated she did not provide Resident #2 with Cozaar and held it. MA C stated she signed the MAR as administered by mistake and stated she did not notify any nurse about Resident #2's blood pressure being out of parameters and medication being held and stated she should have notified the nurse. MA C did not recall who the overnight nurse was. MA C stated she had received in-services over signing the MAR. During an interview with MA B on 04/29/25 at 2:42pm she stated she worked with Resident #2 on 04/20/25 and was responsible for administering Resident #2's medication. MA B stated prior to administering Cozaar she needed to look at the parameters, MA B stated she checked Resident #2's blood pressure and it was 114/68 and stated based on that reading it should not have been administered. MA B stated she assumed the parameters for Resident #2 were the same as before because they never had parameters like Resident #2's at the facility before. MA B stated the blood pressure parameters at the facility were all almost the same and were usually 100/60 and stated this one kind of slipped on us and she stated after she took Resident #2's blood pressure she gave her the Cozaar medication and Resident #2 spit it out due to being nauseous. MA B stated that because she had placed the medication in Residents #2's mouth she documented it as administered. MA B stated she could have written a note about the administered and spit out medication but did not, MA B stated she probably just forgot to write a note because they were busy most of the time. MA B stated she thought she had told a nurse about Resident #2 being administered her Cozaar and then spitting it out but could not remember. MA B stated she had received in-services over signing the MAR and following the parameters after the incident had occurred. MA B stated the facility policy for medication parameters stated to always take the blood pressure before administering. MA B stated she had not followed the facility policy due to not reading the parameters. MA B stated it was important to review orders, parameters, and directions prior to administering medication because it was procedure and important for the resident safety. MA B stated providing blood pressure medication to a resident who was not within parameters could be negatively impacted because their blood pressure could go down. During an interview with MA A on 05/13/25 at 8:57am she stated she worked with Resident #2 on 04/19/25 and was responsible for administering Resident #2's medication. MA A stated prior to administering Cozaar she needed to see how the patient was and check their blood pressure and compare it to the parameters listed on the order to see if they would receive the medication or not. MA A stated on 04/19/25 she checked Resident #2's blood pressure but did not recall the exact reading and stated she thought it was 100 or 114 over 70. MA A was shown Resident #2's April 2025 MAR that revealed a blood pressure of 106/62, MA A stated based on the blood pressure her Cozaar should not be administered. MA A stated she did not administer Cozaar to Resident #2 on 04/19/25 and stated she should have coded it as 4 which she stated indicated the resident was out of parameters and the medication could not be given. MA A stated she did not know why she signed it as administered and stated she was just in a rush. MA A stated she should have notified the nurse that the Resident #2's blood pressure was out of parameters and that the medication would be held, MA A did not remember if she notified the nurse. MA A stated she had received in-services over signing the MAR. MA A stated she did not recall seeing a facility policy over accurately documenting on the MAR. MA A stated incorrect documentation could negatively impact a residents health. During a follow up interview with MA C on 05/13/25 at 2:55pm MA C stated she would have to go to her DON for what the facility policy stated over accurately documenting on the MAR. MA C stated incorrect documentation could negatively impact them really bad and stated she did not know what to answer. During an interview with the DON on 05/13/25 at 5:29pm she stated MA A was responsible for administration and documentation on the MAR for Resident #2's Cozaar on 04/19/25, MA B was responsible on 04/20/25 and MA A on 04/21/25. The DON stated the staff had to check the blood pressure and pulse prior to administering and stated a blood pressure under 120/60 or a pulse under 60 would require the medication to be held. The DON stated all 3 staff members checked Resident #2's blood pressure and stated her Cozaar should not have been administered on any of the 3 days based on her blood pressure of 106/62 on 04/19/25, 114/68 on 04/20/25 and 106/71 on 04/21/25. The DON reviewed Resident #2's April 2025 MAR and confirmed the blood pressure of 106/62 on 04/19/25, 114/68 on 04/20/25 and 106/71 on 04/21/25. The DON stated MA A and C did not administer the medication on 04/19/25 and 04/25. The DON stated MA A and MA C signed as administered in error and stated it should have been coded as out of parameters. The DON stated MA B gave the medication to Resident #2 but she spit it out. The DON stated she did not know why MA B administered Cozaar to Resident #2 when she had her blood pressure out of parameters and stated it was a mistake she overlooked. The DON stated staff had been trained to check the blood pressure, look at the parameters and to notify the nurse if out of parameters and to document if given or not. The DON stated MA B could have written a note and should have documented it as not administered and should have notified the nurse of the blood pressure being out of parameters and being held. The DON stated in all 3 situation the staff should have notified the nurses and stated they had not based on what she knew. The DON stated all 3 staff had been trained on signing the MAR and following medication parameters. The DON stated all 3 staff were trained immediately after and prior but could not recall when. The DON stated the facility policy for accurately documenting on the MAR and following parameters for medication stated they were responsible for accurately documenting on the medication MAR and following physician orders. The DON stated the 3 staff did not follow the facility policies. The DON stated incorrect documentation on the MAR could negatively impact the resident because it reflected something was provided when it was not. The DON stated providing blood pressure medication to a resident whose blood pressure was not in parameter could negatively impact them on a case by case basis and could lower the blood pressure. The DON stated she determined staff were competent to provide residents medication while following the order in place by doing medication pass audits, training, and competencies. The DON stated all 3 staff have completed competencies for order, parameters and documentation. Record review of Medication Pass Competency Assessment dated 07/03/24 for MA A, MA B and MA C reflected they were checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/28/25 for MA A, reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/29/25 for MA B reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review of Medication Pass Competency Assessment dated 04/30/25 for MA C reflected she was checked off as met for, MAR is read prior to preparing medications. And checked pulse and/or blood pressure and recorded prior to med administration when orders/indicated and Medication held if Vital signs were not within the parameters as ordered and Residents refusal of medication is recorded. Record review on facility Inservice dated 04/21/25 that covered topic of FOLLOW MD ORDERS AND PARAMETER FOR MEDICATION ADMINISTRATION with a summary of, CMAS AND CHARGE NURSES SHOULD FOLOW THE MD ORDERS WHEN ADMINISTER [administering] MEDICATIONS AS WELL AS MEDICATION ADMINISTRATION PARAMETERS. CMAS SHOULD NOTIFY CHARGE NURSE WHEN HOLDING MEDCIATION AND WHEN RESIDENT REFUSE MEDICATION CHARGE NURSE TO NOTIFY MD OF MEDICAITON REFUSALS AND WHEN MEDICZTIONS ARE HELD. Revealed MA A, MA B and MA C had all received the education. Record review of employee counseling report dated 04/21/25 revealed MA C had documented the administration of medication however no medication was required or administered per the residents' parameters. Record review of facility policy titled Medication Administration with an implementation date of 10/24/22 stated, 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside of the physician prescribed parameters. and 19. Report and document any adverse side effects or refusals. And 20. Correct any discrepancies and report to nurse manager.

Based on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #31) of 6 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document in the treatment administration record when Resident #31 received supplemental oxygen. This failure could result in residents' records not accurately reflecting the administration of treatments and could result in further error and a decline in heath. The findings included: Record review of Resident #31's face sheet dated 09/26/24 reflected an [AGE] year-old female with an admitted [DATE] and an original admitted [DATE]. Pertinent diagnoses included Dementia (loss of cognitive functioning that interferes with daily life activities), and Diastolic Heart Failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly) Record review of Resident #31's Comprehensive MDS assessment section C, cognitive patterns, dated 09/05/24 reflected an inability to obtain a BIMS score due to Resident #31's status as rarely/never understood. MDS assessment section O, special treatments, procedures, and programs reflected Resident #31 had not received oxygen therapy in the past 14 days at the facility. Record review of Resident #31's care plan reflected the problem [Resident #31] had altered respiratory status/difficulty breathing r/t SOB, Anxiety initiated on 10/14/22. An intervention to treat the problem reflected Oxygen at 2 LPM via nasal canula as needed as per MD orders initiated on 11/04/22. Record review of Resident #31's order summary reflected an active order dated 11/03/22 for Oxygen at 2 LPM via nasal canula every 2 hours as needed for hypoxia [condition that occurs when the body or a part of the body does not receive enough oxygen] if < 92% Record review of Resident #31's MAR on 09/26/24 reflected the order for Oxygen at 2 LPM via nasal canula every 8 hours as needed for hypoxia IF < 92% had not been administered during the month of August 2024 and September 2024. During an observation at 8:53 AM on 09/24/24, Resident #31 laid in bed in her room and received 2 LPM of oxygen via nasal canula. Interview with Resident #31 was attempted at 8:53 AM on 09/24/24, but Resident #31 was unable to communicate back with this surveyor. During an observation at 10:49 AM on 09/26/24, Resident #31 laid in bed in her room and received 2 LPM of oxygen via nasal canula. During an interview with the MDS coordinator at 10:52 AM on 09/26/24, the MDS coordinator stated the Comprehensive MDS assessment dated [DATE] indicated Resident #31 did not receive oxygen therapy in the last 14 days. The MDS coordinator stated the MAR showed Resident #31 had not received oxygen therapy in the months of August 2024 and September 2024. During an interview with LVN A at 12:49 PM on 09/26/24, LVN A stated Resident #31 will use the 2 LPM oxygen as needed on some days. LVN A stated Resident #31 goes through periods where she needed it more and some where she needed it less. LVN A stated Resident #31 was on oxygen earlier this morning, but Resident #31's oxygen level was at 98% so she took Resident #31 off the oxygen at around 11:45 AM this morning. LVN A stated the nurse who administered the oxygen should be the one to sign the MAR that it was completed. LVN A stated she arrived at 6 AM but did not recall if Resident #31 was on oxygen when she arrived in the morning. LVN A stated if nurses did not sign the MAR when administering treatment, a resident could get a double dose of medication. LVN A stated if they did not sign the MAR then they would not have a record of how much oxygen Resident #31 was using. During an interview with the ADON at 1:03 PM on 09/26/24, the ADON stated Resident #31 received PRN oxygen sometimes. The ADON stated every time a resident received a PRN treatment, the nurse administering the treatment should sign the MAR. The ADON stated it was important to document how much oxygen Resident #31 received so they can make more informed treatment decisions about the resident in the future. During an interview the DON at 1:10 PM on 09/26/24, the DON stated she visited Resident #31 today at around 12:00PM and she was not on oxygen. The DON stated she had seen Resident #31 on oxygen this month but did not remember specific days or times. The DON stated if the order was PRN and it was administered, the nurse who administered the treatment should sign the MAR. The DON stated if Resident #31 was on oxygen, but it was not on the MAR then it would not reflect reality. The DON stated it was important to keep a record of how often the resident used oxygen so they can make adjustments to the order as needed. A policy for medication administration was requested from the administrator on 09/26/24 but none was provided.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Cook E) of 3 kitchen staff reviewed for storage, preparation and sanitation. The facility failed to ensure [NAME] E performed hand hygiene for at least 20 seconds while prepping resident meals for breakfast. This failure could place residents at risk for cross-contamination and infections. The findings included: During a kitchen tour observation on 09/24/24 at 7:17 AM [NAME] E was observed washing her hands for 5 seconds after picking up an item off the kitchen floor. During a second observation on 09/24/24 at 7:31 AM [NAME] E was observed washing her hands for 3 seconds after taking food temperatures. In an interview on 09/24/24 at 07:30 AM [NAME] E stated handwashing should be done for 20 seconds as to avoid cross-contamination in food and spreading germs to residents. [NAME] E stated she dropped something on the floor and after picking it up, she went to wash her hands and became nervous because she knew she was being watched. [NAME] E stated she was last in-serviced on handwashing a few weeks ago but could not remember the date. In an interview on 09/24/24 at 01:29 PM the DM stated all staff should wash hands for at least 20 seconds as they are in-serviced regularly. The DM stated if hands were not washed it could lead to cross-contamination of food that was served to the resident. The DM stated she was going to conduct an in-service on hand hygiene immediately to all kitchen staff as to prevent cross-contamination to food. In an interview on 09/26/24 at 09:49 AM the ADON/Infection Control Preventionist, stated handwashing should be done for 20 to 30 seconds. The ADON stated handwashing should be done appropriately to stop the spread of infections and bacteria to residents, staff, and visitors. The ADON stated when infection control and handwashing in-services are conducted monthly, all staff including kitchen staff are in-serviced. The ADON stated it was important for all staff including kitchen staff to wash hands appropriately as they handle food. In an interview on 09/26/24 at 09:53 AM the DON stated handwashing should be at least 20-30seconds to prevent the spread of bacteria or germs to residents, staff, and visitors. The DON stated and record review revealed, a hands-on in-service on handwashing was conducted on 9/25/24 for all staff. Record review of facility's Hand Hygiene policy dated 10/24/22 stated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 5. Hand hygiene technique when using soap and water: c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. References: FDA Food Code 2022 Title 21, Chapter 1, Subchapter B S 112.32: Washing hands thoroughly, including scrubbing with soap (or other effective surfactant) and running water that satisfies the requirements of S 112.44(a) (as applicable) for water used to wash hands, and drying hands thoroughly using single-service towels, sanitary towel service, electric hand dryers, or other adequate hand drying devices: (i) Before starting work; (ii) Before putting on gloves; (iii) After using the toilet; (iv) Upon return to the work station after any break or other absence from the work station; (v) As soon as practical after touching animals (including livestock and working animals), or any waste of animal origin; and (vi) At any other time when the hands may have become contaminated in a manner that is reasonably likely to lead to contamination of covered produce with known or reasonably foreseeable hazards.

Based on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Resident #34) reviewed for comprehensive care plans. Resident #34's comprehensive care plan was not revised after the code status was changed from DNR to a Full Code. This failure could place residents at risk for inadequate care during an emergent situation. The findings included: Record review of Resident #34's face sheet dated [DATE] reflected a [AGE] year-old-male with an original admitted [DATE]. Diagnoses included bone cancer, chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), and type two diabetes (insufficient production of insulin in the body). Record review of Resident #34's care plan dated [DATE] and revised on [DATE] stated Resident #34 was a DNR. Interventions included: Ensure signed DNR is in medical record. If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Record review of Resident #34's physician orders dated [DATE] reflected a code status of CPR (full code). In an interview on [DATE] 03:04 PM the MDS Coordinator stated Resident #34 was supposed to be a full code and the care plan should have reflected Resident #34's current code status. The MDS Coordinator stated Resident #34 used to be a DNR. The MDS Coordinator stated Resident #34 had gone to the hospital sometime in June or July of this year and when he returned to the facility from the hospital, Resident #34 and family wanted the code status to be changed to full code. The MDS Coordinator stated Resident #34's code status was overlooked. The MDS Coordinator stated staff follows the code status that was found at the top the of the chart which did state Resident #34 was a full code. The MDS Coordinator stated the DNR code status should have been removed and the care plan updated so it would have Resident #34's individualized plan of care. The MDS Coordinator stated she was going to correct Resident #34's care plan immediately. In an interview on [DATE] 09:55 AM the DON stated Resident #34's care plan should have been updated when the change in code status happened. The DON stated Resident #34 used to be a DNR and was on hospice services. The DON stated Resident #34 came back to the facility from the hospital and Resident #34 and his family agreed for the code status be updated to a full code. The DON stated Resident #34's care plan should match the correct code status so staff are able to know the correct plan of care and what action to take in case of an emergency. The DON stated the IDT looks over care plans and are audited quarterly or as needed. The DON stated Resident #34's care plan was missed. The DON stated she felt Resident #34 was not affected by the care plan not having the correct code status as the correct code status was in the Resident #34's chart and physician orders. Record review of facility's Care Plan Revision Upon Status Change policy dated [DATE] stated: Policy: The purpose of this procedure is to provide a consistent process for reviewing process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #8) of 6 residents reviewed for respiratory care in that: 1, The facility failed to date and/or change the suction canister, suction tubing, and suction device for Resident #8. 2. The facility failed to ensure there was a physician order to change the suction canister, suction tubing, suction device, oxygen tubing, and nebulizer for Resident #8. These failures could place residents that had a need for oxygen or suctioning at risk of infection. The findings included: Record review of Resident #8's Admission record reflected a [AGE] year-old male that had an original admitted [DATE] and was readmitted on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), Congestive Heart Failure (the heart does not beat effectively enough and can cause fluid buildup in the lungs), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and Dementia (loss of memory, language, problem-solving and other thinking abilities). Record review of Resident #8's Quarterly MDS dated [DATE] reflected a BIMS score of 2 which indicated Resident #8 had severe cognitive impairment. Resident #8's MDS also reflected that he was coded for oxygen therapy while a resident. Record review of Resident #8's comprehensive care plan reflected in part: Problem: Resident #8 has COPD and COPD with exacerbation (an increase in difficulty breathing). Initiated: 2/17/18, revised 3/8/21. Goal: Resident #8 will be free of signs/symptoms of respiratory infections through review date. Initiated: 2/17/18, revised: 3/6/24, target date: 11/26/24. Interventions: Give aerosol, nebulizer treatments or bronchodilators as ordered. Monitor/ document any side effects and effectiveness. Initiated: 2/17/18, revised: 5/12/21. Monitor for difficulty breathing on exertion. Initiated: 2/17/18, revised: 11/2/18. Monitor/document/report PRN (as needed) any signs/symptoms of respiratory infection: fever, chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing. Initiated 2/17/18. Record review of Resident #8's physician orders on 9/26/24 reflected an order dated 9/24/24 that stated, Oxygen at 3 lpm (liters per minute) via nasal cannula every shift for hypoxia, and an order dated 8/30/24 that stated, Suctioning by mouth every 8 hours as needed for congestion. There were no orders found that related to changing out oxygen or suction supplies. Observation of Resident #8's room on 9/24/24 at 9:31am revealed a suction canister was on top of a rolling table next to Resident #8's bed. The suction canister did not have a date on it and had approximately 400ml of a clear colored cloudy liquid inside. There was suction tubing connected to the suction canister on one end and to a Yankauer suction device (hard suction device used to suction secretions out of the mouth) on the other end. The suction tubing was not dated and the Yankauer suction device was slid into its previously opened packaging. The date on the Yankauer suction device packaging was 9/16/24. Observation of Resident #8's room on 9/26/24 at 9:02am revealed the suction canister was in the same location as before but had been dated 9/23 with [initials] below it written with black marker on the lid of the suction canister. The suction canister still contained approximately 400ml of a clear colored cloudy liquid. The suction tubing was still attached to the suction canister at one end and to the Yankauer suction device (hard suction device used to suction secretions out of the mouth) at the other end. The Yankauer suction device was still in the packaging dated 9/16/24. In an interview on 09/26/24 at 9:21am, RN B stated the suction canisters were one time use for a week. RN B stated they would change them out sooner than a week if they were smelly or if the resident had some kind of respiratory infection. RN B stated the suction tubing and Yankauer were supposed to be changed out weekly or as needed if soiled, as was the oxygen tubing. RN B stated the Yankauer, and suction tubing should have been changed when the canister was. RN B stated he last worked Monday night and if he would have had to suction Resident #8, he would have changed out the suction supplies, but Resident #8 has not needed to be suctioned. RN B stated if Resident #8 had needed a nebulizer treatment, he would check the date on the oxygen tubing and nebulizer and change it if it was over a week old. RN B stated he was going to go change out the suction supplies at the end of the interview. RN B stated if the supplies were not changed out, nosocomial infection, bacterial growth, and hospitalization could occur. In an interview on 9/26/24 at 9:49am the ADON stated suction supplies were to be changed every 7 days and as needed. The ADON stated if the suction or oxygen supplies were not changed out, bacteria could start to grow, and it could cause infection for the resident. The ADON stated, With the Yankauer dated 9/16/24, it makes me doubt the 9/23 date on the canister. The ADON stated [initials] might have been the respiratory therapist, but they did not have a nurse with those initials. The ADON stated the respiratory therapist had not been to the facility to see a resident for at least four days. The ADON stated the respiratory therapist worked as needed and would come in to see specific patients or do in-services. The ADON stated the did do in-service on supplies and the last one was in August for all staff. The ADON stated it was on the orders when the oxygen tubing was supposed to be changed out. In an interview on 9/26/24 at 9:53am the DON stated disposable supplies were to be changed out weekly or as needed if they were soiled. The DON stated if suction and oxygen supplies were not changed out, it could cause infection and possibly hospitalization . Record review of the facility's Infection Prevention and Control Program Policy dated 5/13/23 reflected in part: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. 2. All staff are responsible for following all policies and procedures related to the program. 10. Equipment Protocol: a. Single use disposable equipment is an alternative to sterilizing reusable medical instruments. Single use devices must be discarded after use and are never used for more than one resident. 11. Supplies Protocol: a. Sterile supplies shall be appropriately packaged and sterilized or purchased prepackaged and sterile from the manufacturer. b. Prepackaged sterile items are considered sterile until opened or damaged. Packaging shall be inspected prior to use. 16. Staff Education: a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b. All staff shall demonstrate competence in resident care procedures established by our facility.