Every finding on record at Estates at Shavano Park

Based on observations, interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 (#1) for infection control residents in that: CNA A and CNA B transferred Resident #1 from a high back wheelchair to a bed and did not have on gowns. Resident #1 was on EBP due to tube feeding status. This failure could place residents at risk for infections. Findings:Record review of Resident #1's admission Record dated 8/20/2026 reflected an [AGE] year male admitted on [DATE] with diagnoses of Dysphagia (difficulty or pain when swallowing food, liquids, or saliva). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected under Nutritional Approaches, that the resident received nutrition through a feeding tube. Record review of Resident #1's Care plan dated 7/12/2026 reflected he was NPO (nothing by mouth) and was administered Tube feeding nutrition as ordered. Resident #1 required tube feeding related to dysphagia. Record review of Resident #1's consolidated orders for August 2026 reflected enteral feed order every shift Jevity 1.2 or interchange if needed with (isosource HN 1.2) at 70 milliliter an hour to provide 1848 calories, 81 grams of protein and 1212 milliliter free water. Additional fluid needs are 628 milliliters per day. 150 milliliter every 2 hours. Observation on 8/18/2026 at 11:52 AM during a Mechanical lift transfer with CNA A and CNA B revealed the staff transferred Resident #1 from a high back wheelchair to his bed without wearing a gown. Resident #1 was on tube feeding and machine was off during the transfer. Near Residet #1's entrance, on the wall, was a small, 4 by 6 inches posting that reflected staff during contact with a resident were required to wear gown and gloves. In an interview on 8/18/2026 at 11:57 AM, CNAs A and B stated they did not know Resident #1 was on EBP and confirmed they did not wear gown during the Mechanical lift transfer. They were shown the posting at the entrance of Resident #1's room and they did not see the posting, In an interview on 8/18/2026 at 12:01 PM, LVN C stated Resident #1 was on EBP due to his tube feedings, and during contact, staff were to wear a gown and gloves. LVN C stated if staff go into Resident room with contact precautions and making contact, staff must wash hand, put gloves on and a gown during transfer. In an interview on 8/18/2026 at 4:45 PM, the DON stated the staff did let her know about them not wearing a gown during resident transfer. The DON stated staff were to wear gowns and gloves during contact with a resident on EBP and were trained. Record review of the facility's Enhanced Barrier Precautions, dated December 2025 reflected Enhanced Barrier Precautions (EBP) refer to infection control intervention designed to reduce transmission of multi-drug, resistance organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunctions with standard precautions and expand the use of PPE to donning gown and glove use during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 4. Gowns- A period wear a gown (clean, non-sterile) to protect skin and prevent soiling a clothing during high contact resident care activities such as dressing transferring.

Based on interviews and record reviews, the facility failed to ensure that Residents were free of significant medication errors, for 3 of 8 residents (Residents #14, #23, and #27), reviewed for significant medication errors. Staff administered midodrine incorrectly per the physicians' orders, to Residents #14, #23, and #27. Midodrine is an oral medication that increases blood pressure by constricting blood vessels. It is used to treat severe drops in blood pressure upon standing. It is usually taken three times daily during waking hours. These failures could place residents at risk for injuries from low or high blood pressure.The findings include: 1. A record review of Resident #14's admission record, dated 3/11/2026, revealed Resident #14 was admitted to the facility on [DATE]. Resident #14 had diagnoses which included hypertension (high blood pressure), hypotension (low blood pressure), and dementia (a general term for a decline in mental ability-such as memory, reasoning, and behavior-severe enough to interfere with daily life). A record review of Resident #14's annual MDS assessment, dated 11/30/2025, revealed Resident #14 was a [AGE] year-old female who was admitted for long term care. Resident #14 was assessed with a BIMS score of 15 out of a possible 15, which indicated no cognitive impairment. A record review of Resident #14's care plan, dated 3/11/2026, revealed, I have hypertension . give antihypertensive medications as ordered . A record review of Resident #14's physicians orders, dated 3/11/2026, revealed the physician prescribed on 6/8/2025 for Resident #14 to receive midodrine 10mg three times a day for low blood pressure and for staff to not give the medication if the systolic blood pressure was greater than 120. A record review of Resident #14's October 2025 medication administration record revealed staff administered midodrine contrary to the physicians' orders, 20 times out of a potential 90 opportunities, as follows:- 10/2/2025 at 8:00 AM, MA E did not administer the midodrine when Resident #14 had low blood pressure, a SBP pressure of 114.- 10/3/2025 at 8:00 AM, MA E did not administer the midodrine when Resident #14 had low blood pressure, a SBP pressure of 108.- 10/3/2025 at 12:00 PM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 126.- 10/8/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 127. - 10/8/2025 at 12:00 PM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 138. - 10/9/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 100. - 10/9/2025 at 12:00 PM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 122. - 10/12/2025 at 4:00 PM, MA I administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 126. - 10/14/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 116. - 10/15/2025 at 8:00 AM, LVN J administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 134. - 10/15/2025 at 12:00 PM, LVN J administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 126. - 10/18/2025 at 4:00 PM, MA K administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 121. - 10/20/20/20/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 103. - 10/20/20/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 118. - 10/21/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 118. - 10/21/2025 at 12:00 PM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 122. - 10/26/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 133. - 10/26/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 111. - 10/27/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 118. - 10/27/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 104. - 10/29/2025 at 8:00 AM, LVN J administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 127. A record review of Resident #14's November 2025 medication administration record revealed staff administered midodrine contrary to the physicians' orders, 34 times out of a potential 90 opportunities, as follows: - 11/2/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 122. - 11/2/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 119. - 11/3/2025 at 4:00 PM, MA L administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 129. - 11/7/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 119. - 11/7/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 119. - 11/8/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 104. - 11/8/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 104. - 11/9/2025 at 8:00 AM, MA M administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 124. - 11/10/2025 at 8:00 AM, MA M administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 125. - 11/10/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 130. - 11/11/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 137. - 11/11/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 120. - 11/12/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 107. - 11/12/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 104. - 11/13/2025 at 4:00 PM, MA F did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 122. - 11/14/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 133. - 11/15/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 121. - 11/16/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 123. - 11/17/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 101. - 11/18/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 146. - 11/19/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 124. - 11/21/2025 at 8:00 AM, MA N administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 128. - 11/22/2025 at 8:00 AM, MA N administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 128. - 11/23/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 109. - 11/23/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 113. - 11/24/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 115. - 11/24/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 111. - 11/25/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 122. - 11/28/2025 at 4:00 PM, MA F administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 145. - 11/29/2025 at 8:00 AM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 109. - 11/29/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 101. - 11/30/2025 at 8:00 AM, MA E administered midodrine when Resident #14 had blood pressure higher than the physician ordered, a SBP pressure of 126. - 11/30/2025 at 12:00 PM, MA E did not administer midodrine when Resident #14 had low blood pressure, a SBP pressure of 113. During an interview on 3/11/2026 at 1:46 PM, MA E stated he was the Medication Aide for Resident #14 on [TF7] 3/11/2026 from 6:00 AM to 2:00 PM. MA E stated Resident #14 was prescribed Midodrine with instructions to give the medication when Resident #14 had low blood pressure. MA E recalled an unknown LVN, who did not work at the facility anymore, had told him specifically for Resident #14 to not give her the Midodrine for episodes of low blood pressure. MA E stated he did not administer Resident #14's midodrine in the morning when she had a low blood pressure of 109/64 and again at noon when she had low blood pressure of 106/66. MA E stated he believed midodrine raised blood pressure but was uncertain. MA E stated the nurse on duty was LVN G. MA E stated he had not reported the held dosages of midodrine to anyone. MA E stated he had also administered midodrine to other residents in the facility and could not recall their names without a record review. During an interview on 3/11/2026 at 1:58 PM, the ADON stated Resident #14 [TF9] was prescribed midodrine 10mg for hypotension and had physicians' parameter to not administer the medication when Resident #14 had a blood pressure greater than 120 SBP. The ADON stated she reviewed the medication administration record for Resident #14 and recognized on 3/11/2026 at 9 AM Resident #14 had a blood pressure of 109/64 and MA E did not administer the midodrine and again on 3/11/2026 at noon Resident #14 had a blood pressure of 106/66 and MA E did not administer the midodrine. The ADON stated MA E should have administered the medication. The ADON stated MA E should have reported the held medications to the nurse. The [TF10] ADON stated she had not received a report Resident #14 had any medications held. The ADON stated if she had received a report, she would have assessed Resident #14 for adverse reactions for her not receiving her prescribed medications[TF11] . 2. A record review of Resident #23's admission record, dated 3/13/2026, revealed Resident #23 was admitted to the facility on [DATE]. Resident #23 had diagnoses which included hypertension (high blood pressure), hypotension (low blood pressure), and dementia (a general term for a decline in mental ability-such as memory, reasoning, and behavior-severe enough to interfere with daily life). A record review of Resident #23's quarterly MDS assessment, dated 1/1/2026, revealed an [AGE] year-old male who was admitted for long term care. Resident #23 was assessed with a BIMS score of 10 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #23's care plan dated 3/11/2026 revealed, I have hypertension . give antihypertensive medications as ordered . A record review of Resident #23's physicians orders, dated 3/11/2026, revealed the physician prescribed on 10/16/2025 for Resident #23 to receive midodrine 10mg three times a day for low blood pressure and for staff to not give the medication if the systolic blood pressure was greater than 120. A record review of Resident #23's March 2026 medication administration record revealed staff administered midodrine contrary to the physicians' orders, 8 times out of a potential 30 opportunities, as follows: - 3/4/2026 at 9:00 PM, MA O administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 128. - 3/6/2026 at 5:00 PM, MA L administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 130. - 3/7/2026 at 9:00 AM, MA E administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 125. - 3/7/2026 at 1:00 PM, MA E administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 126. - 3/7/2026 at 5:00 PM, MA E administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 122. - 3/9/2026 at 1:00 PM, MA M administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 123. - 3/9/2026 at 5:00 PM, MA L administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 124. - 3/11/2026 at 9:00 PM, ADON administered midodrine when Resident #23 had blood pressure higher than the physician ordered, a SBP pressure of 130. 3. A record review of Resident #27's admission record, dated 3/13/2026, revealed Resident #27 was admitted to the facility on [DATE]. Resident #27 had diagnoses which included hypertension (high blood pressure), hypotension (low blood pressure), and dementia (a general term for a decline in mental ability-such as memory, reasoning, and behavior-severe enough to interfere with daily life). A record review of Resident #27's quarterly MDS assessment, dated 11/29/2025, revealed Resident #27 was an [AGE] year-old male who was admitted for long term care. Resident #27 was assessed with a BIMS score of 15 out of a possible 15, which indicated no cognitive impairment. A record review of Resident #27's care plan, dated 3/11/2026, revealed, I have altered cardiovascular status related to hypertension . give antihypertensive medications as ordered . I have orthostatic hypotension (a sudden drop in blood pressure occurring when standing up from a sitting or lying position. It causes dizziness, lightheadedness, blurred vision, or fainting due to inadequate blood flow to the brain) . give medications as ordered . A record review of Resident #27's physicians orders, dated 3/11/2026, revealed the physician prescribed on 2/16/2025 for Resident #27 to receive midodrine 5mg two times a day for low blood pressure and for staff to not give the medication if the systolic blood pressure was greater than 120. A record review of Resident #27's March 2026 medication administration record revealed staff administered the midodrine contrary to the physicians' orders, 8 times out of a potential 20 opportunities, as follows: - 3/1/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 138. - 3/2/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 133. - 3/3/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 147. - 3/4/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 147. - 3/7/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 135. - 3/8/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 140. - 3/9/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 147. - 3/10/2026 at 9:00 PM, MA F administered midodrine when Resident #27 had blood pressure higher than the physician ordered, a SBP pressure of 140. During an interview on 3/11/2026 at 10:20 AM, the Medical Director stated he had not received a report that residents had not received their midodrine as prescribed. The Medical Director stated his expectations were for the staff to follow physicians' orders and administer medications as prescribed. The Medical Director stated the drug midodrine was a drug which could raise a person's blood pressure and if given incorrectly could raise a person's blood pressure beyond intended therapeutic effects - or - the resident may not receive the therapeutic effects of the medication if the medication was not administered when the resident needed the medication. During an interview on 3/13/2026 at 11:00 AM, the DON stated the expectation was for staff to administer medications as prescribed. The DON stated she received reports that some residents had not received their midodrine as prescribed. The DON stated she reviewed all residents who received midodrine and recognized Residents #14, #23 and #27 had not received their medications as prescribed by the physician. The DON stated she assessed the residents for safety and had not discovered any injuries. The DON stated she had begun corrective actions which included re-enforced training and supervision for the identified nursing staff and re-enforced training for all the nursing staff. The DON stated the potential negative outcome for Residents who had not received their midodrine as prescribed by the physician could be they may not have received the intended therapeutic effects of their medications. A record review of the facility's Administering Oral Medications policy, dated December 2025, revealed, . Preparation, verify that there is a physician's medication order for this procedure. Review the residence care plan to assess for any special needs of the resident, . Steps in procedure . select the drug from the unit dose drawer or stock supply, check the label on the medication and confirm the medication name and dose with the medication administration record, check the medication dose. Recheck to confirm the proper dose.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, ensured all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 24 residents (Resident #2 and #70) and 1 of 3 medication carts (300-hall even nursing cart) reviewed for medication storage. 1. The facility failed to ensure Resident #2's three bottles of normal saline, used for flushing the resident's indwelling urinary catheter, were not left unattended in the resident's room on 03/10/2026. 2. The facility failed to ensure Resident #70's moisture barrier ointment cream was not left unattended inside the resident's restroom, on 03/10/2026. 3. The facility failed to ensure the 300-hall nursing cart was not unlocked and left unattended at the 300-hall on 03/12/2026. These failures could place residents at risk of not using medications correctly and medication diversion.The findings were: 1. Record review of Resident #2's face sheet, dated 03/13/2026, revealed an [AGE] year-old male who was admitted to the facility 01/23/2026. Resident #2 had diagnoses which included lack of coordination (poor muscle control that causes clumsy movement), urinary tract infection (an infection in any part of the urinary system, such as bladder), and muscle weakness. Record review of Resident #2's admission MDS assessment, dated 01/27/2026, revealed the resident's BIMS score was 12 out of 15, which indicated the resident had moderate cognitive impairment. Resident #2 had an indwelling urinary catheter. Record review of Resident #2's physician's order, dated 01/29/2026, revealed the resident had an order for Foley Catheter [indwelling urinary catheter] 20 French with 10milliters balloon. Observation on 03/10/2026 at 9:53 a.m. revealed Resident #2 was sleeping in the bed, the resident had an indwelling urinary catheter, and there were three bottles of normal saline on the resident's window frame. Interview on 03/10/2026 at 11:35 a.m., LVN-U said there were three bottles of normal saline on the resident's room window frame that were left unattended and the normal saline was for flushing the resident's indwelling urinary catheter. LVN U said facility nurses might leave three bottles of normal saline unattended after flushing the resident's catheter, and they should have been stored in a nursing cart to prevent possible inappropriate using. 2. Record review of Resident #70's face sheet, dated 03/13/2026, revealed an [AGE] year-old female who was admitted to the facility 09/18/2026. Resident #70 had diagnoses which included lack of coordination (poor muscle control that causes clumsy movement), difficulty in walking, and type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar [glucose] levels). Record review of Resident #70's quarterly MDS assessment, dated 12/26/2025, revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact. Resident #70 did not have any skin injury. Record review of Resident #70's comprehensive care plan, dated 10/01/2025, revealed Resident is at risk for additional pressure ulcers related to decreased mobility. For intervention - Follow facility policies/protocols for the prevention/treatment of skin breakdown. Observation on 03/10/2026 at 10:33 a.m. revealed Resident #5 was not in the room, but there was an ointment cream tube of Calmoseptine Ointment for protect and helps heal skin irritations left unattended inside the resident's restroom. Interview on 03/10/2026 at 11:46 a.m., the wound care nurse said there was one tube of Calmoseptine ointment, for protection and helped heal skin irritation, left in Resident #70's restroom unattended, and the cream was a medication, so it should have been stored in a nursing cart to prevent possible inappropriate use. 3. Observation on 03/12/2026 at 8:41 a.m. revealed the 300-hall nursing cart was parked at the 300-hallway. The cart was unlocked and nobody was supervising the cart. Interview on 03/12/2026 at 8:52 a.m., LVN-A stated the 300-hall nursing cart which was parked at the 300-hall was unlocked and left unattended. The nurse said she had responsibility for locking her cart all the times and she forgot to lock the cart when she left from the cart to see some residents, and it was her mistake. The nurse stated the nursing cart should have been locked, all the time to prevent somebody from taking any medications. Interview on 03/12/2026 at 8:54 a.m., the DON said the facility nurses should have stored Resident #2's three bottles of normal saline and Resident #70's ointment in a nursing cart and should have locked the nursing carts all the time to prevent somebody to take medications. Record review of the facility's policy, titled Storage of Medications, dated 12/2025, revealed 1. Drugs and biologicals shall be stored in the packaging, containers or others dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The Dietary Manager failed to wear a beard restraint while working in the kitchen.2. Dietary Aide P and Dietary Aide R failed to wear hair restraints or beard restraints while working in the kitchen.3. The facility failed to store wet dishes to allow for air-drying.4. The facility failed to ensure all prepared items in the walk-in refrigerator were labeled and dated with the use by date. 5. The facility failed to store items off the floor in the kitchen's dry storage area.6. The facility failed to take the temperature of soup after heating it in the microwave and prior to it leaving the kitchen. These failures could place residents at risk for food borne illness. Findings include: During an observation of the facility's kitchen on 03/10/2026 at 8:54 AM revealed Dietary Aide P at the dishwasher not wearing a hair restraint or facial hair restraint. The Dietary Manager was wearing a surgical mask that covered his mouth and nose leaving the side of his face which contained facial hair uncovered. Observations of the facility's dry storage revealed a box of 8-ounce (oz) cup lids and a case of canned soup on the floor. Observations of the kitchen's refrigerator revealed an opened jar of grape jelly, a bag with two eggs, a storage container of red sauce, a large pan covered with aluminum foil, a large bottle of soy sauce, and 7 trays of cups with liquid in them being stored without labels identifying items or dates items were to be used by. Observation of the dish storage area revealed a stack of 8 bowls right side up with liquid pooling inside them. During an observation of the facility's kitchen on 03/10/2026 at 8:54 AM revealed Dietary Aide P wore a surgical mask that covered his mouth and nose leaving the side of his face which contained facial hair uncovered.Interview with the Dietary Manager on 03/10/2026 at 9:03 AM revealed he was wearing a surgical mask as a hair restraint. The Dietary Manager stated hair restraints covering all hair were to be worn while in the kitchen. The Dietary Manager stated it was important to wear hair restraints to prevent hair from falling into food which could cause contamination. The Dietary Manager stated it was the responsibility of each staff to ensure they wore hair restraints properly but ultimately his responsibility to ensure staff wore hair restraints. Observation of [NAME] Q preparing a pureed entree on 03/12/2026 at 11:12 AM revealed [NAME] Q portioned out 9 servings into a bowl. [NAME] Q then prepared the pureed entree and placed it back in the same bowl the 9 whole portions were placed. During an observation of the facility's kitchen on 03/12/2026 at 11:28 AM revealed an opened gallon of milk without a label identifying the date opened or a used by date in the refrigerator.Observation of the facility's kitchen on 03/12/2026 at 4:40 PM revealed the Dietary Manager with his surgical mask below his chin not covering his facial hair. Observation of the facility's kitchen on 03/12/2026 at 5:15 PM revealed [NAME] W opened a can of soup and poured it into a bowl. [NAME] W then placed the bowl in the microwave for 2 minutes. [NAME] W removed the bowl of soup when the microwave completed its cooking time. [NAME] W then placed clear wrap over the bowl and placed the bowl on a resident's tray. The resident's tray was placed on the rack which was then sent to the dining room. Observation of the facility's kitchen on 03/12/2026 at 5:22 PM revealed [NAME] W asked for the bowl of soup to be returned to the kitchen so the temperature could be taken before it was served to the resident. [NAME] W took the temperature of the bowl of soup which was 135 F. Interview with [NAME] Won 03/12/2026 at 5:20 PM revealed [NAME] W did not take the temperature of the soup prior to it being sent to the dining room to be served to a resident. [NAME] W stated the resident requested soup for dinner, so [NAME] W heated up a can of soup in the microwave. [NAME] W did not say why he did not take the temperature of the soup prior to placing it on the resident's tray to be served. [NAME] W stated the failure could have resulted in serving the resident soup that was either too hot causing burns or too cold causing an unenjoyable meal.Interview with [NAME] Q on 03/13/2026 at 6:28 AM revealed staff were to wear hair restraints while in the kitchen to prevent food from being contaminated by hair. [NAME] Q stated contaminated food could cause residents to get sick. [NAME] Q stated it was the responsibility of staff to ensure they wore hair restraints. [NAME] Q stated all items being stored in the refrigerator were to be labeled with the date opened and/or the date to be used by to prevent residents from being served spoiled foods. [NAME] Q stated residents could become ill if served spoiled foods. [NAME] Q stated it was the responsibility of any staff placing prepared or opened food in the refrigerator to label them. [NAME] Q stated it was the dietary aides responsibility to store dishes to allow airflow allowing them to air dry. [NAME] Q stated dishes being stored in a way that did not allow water to dry could cause bacteria to grow causing residents to be sick. [NAME] Q stated all items being stored in the dry storage should be stored on a shelf and off the floor. [NAME] Q was unsure of the height off the floor items were to be stored. [NAME] Q stated it was the responsibility of all staff to ensure items were off the floor in the dry storage area. [NAME] Q was unable to identify how the failure could have potentially affected the residents. Interview with Dietary Aide P on 03/13/2026 at 8:27 AM revealed staff were to wear hair restraints while in the kitchen. Dietary P stated it was his responsibility to ensure he wore it correctly. Dietary P stated if hair restraints were not worn correctly hair could fall into the food and cause residents to get sick. Dietary Aide P stated dishes were to be stored so that water would drain from them and they could air dry. Dietary Aide P stated water sitting in dishes could lead to bacteria growing and causing residents to get sick. Dietary Aide P stated it was the responsibility of the dishwashers to store dishes in a way that allowed them to air dry. Dietary Aide P stated all opened items and prepared foods being stored in the refrigerator were to be labeled with the date they were opened and the date they were to be used by to prevent residents from getting sick. Dietary Aide P stated it was the responsibility of all staff storing items in the refrigerator to ensure they were labeled. Dietary Aide P stated he did not prepare special textured foods and was unaware of the process. Dietary Aide P stated he was trained to store items in the dry pantry on the shelves but stated he did not know why or how it could affect the residents. Dietary Aide P stated it was everyone's responsibility to ensure items were stored properly. Interview with the Dietary Manager on 03/13/2026 at 11:37 AM revealed all staff were to wear hair restraints that covered both facial hair and hair on top of their heads completely. The Dietary manager stated it was the responsibility of the dietary manager to ensure all staff wore hair restraints properly to prevent hair from getting into the food. The Dietary Manager stated residents could get sick by having hair in their food. The Dietary manager stated it was the responsibility of all staff to ensure food being stored in the refrigerator was labeled and dated to prevent residents from being served spoiled foods that could cause illness. The Dietary manager stated dishes were to be stored so they could air dry and to prevent water from collecting in the dishes. The Dietary Manager stated water collecting in dishes could lead to bacteria to grow causing residents to get sick. The Dietary Manager stated it was the responsibility of all staff who washed dishes to ensure they were stored properly. The Dietary Manager stated it was his responsibility to ensure everything in the dry storage was stored properly and included items being stored off the floor. The Dietary Manager stated items needed to be stored off the floor to prevent rodents or bugs from getting into items and potentially causing the residents to get sick. The dietary Manager stated [NAME] W should have taken the temperature of the soup prior to serving. The Dietary Manager stated it was the responsibility of the cook to ensure foods were cooked and maintained at the proper temperatures. The Dietary Manager stated the failure could have caused the resident to burn themselves from food that was too hot or caused illness because food did not get hot enough to kill bacteria. Dietary Aide R was not interviewed because he resigned during the survey and did not return surveyors call. Record review of the facility's policy titled Food Storage, dated 2023, revealed Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves and All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.a. Old stock is always used first (first in - first out method or FIFO). The person designated to manage stock should be trained to rotate it properly.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold or discarded.Record review of the facility's policy titled Employee Hygiene for Food Safety, dated 2023, revealed All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.Record review of the facility's policy titled Cleaning Dishes/Dish Machine, dated 2023, revealed 9. Dishes should be air dried on the dish racks, not dried with towels. 10. Inspect for cleanliness and dryness and put dishes away if clean (be sure hands are clean). Dishes should not be nested unless they are completely dry.Record review of the facility's policy titled Food Temperatures, dated 2023, revealed Food Cooked in a Microwave Oven 165 F (74 C) and hold for 2 minutes after removing from microwave oven.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared 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. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 states Except as provided in, (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 residents out of 20 residents (Resident #72, #3, #19, and #82) reviewed for infection prevention and control measures. 1. NP B and LVN A entered Residents #72 and #3's droplet precaution isolation room without wearing the appropriate PPE. 2. The facility failed to ensure CNA-T performed hand hygiene after changing gloves during incontinent care for Resident #19. 3. The facility failed to ensure MA-M disinfected the blood pressure cuff after using it on another resident. These failures could place residents at risk for contracting infectious diseases. The findings include:A record review of Resident #72's admission record, dated 3/10/2026, revealed an admission date of 11/22/2024. Resident #72 had a diagnosis which included Alzheimer's disease (a progressive, irreversible neurodegenerative brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform simple tasks). A record review of Resident #72's annual MDS assessment, dated 11/29/2025, revealed a [AGE] year-old female who was admitted for long term care with ADLs complicated by Alzheimer's disease. Resident #72 was assessed with a BIMS score of 5 out of a possible 15, which indicated severe cognitive impairment. A record review of Resident #72's orders revealed, on 3/9/2025, the physician ordered Resident #72 to be cared for under an isolation droplet precaution related to her diagnosed flu infection. During an observation and interview on 3/10/2026 at 11:12 AM revealed Resident #72's room door closed and signage and PPE hung on the door. The PPE supplies included surgical masks, gowns, gloves, and a face shield. The signage on the door read Stop Droplet Precautions to prevent the spread of infection anyone entering this room must: hand hygiene, N95 Mask, gloves, gown. LVN A donned a surgical mask and entered into Resident #72's room. LVN A exited Resident #72's room and continued with the surgical mask and upon exiting the room had a conversation with an unidentified CNA. After the short conversation with the CNA, LVN A doffed her surgical mask into the trash. LVN A stated she had donned the surgical mask and no other PPE and entered into Resident #72's room to answer Resident #72's call light and then had exited Resident #72's room, spoke to a CNA and then doffed the surgical mask. LVN A stated Resident #72 was diagnosed with influenza, a respiratory virus which could be spread from 1 person to another and was on isolation droplet precautions. LVN A stated the signage posted on the door instructed anyone who would enter the room to wear PPE to include a N95 FFR, gloves, a gown, and eye protection. LVN A stated she only wore a surgical mask and should have worn gloves and a gown as well. LVN A stated the signage was wrong because her training was to wear a surgical mask, a gown, and gloves. LVN A stated the failure of wearing gloves and a gown could result in the spread of infections. A record review of Resident #3's admission record, dated 3/10/2026, revealed an admission date of 10/8/2025. Resident #3 had diagnoses which included orthopedic aftercare following surgical amputation (resident had a toe amputated) and diabetes type II (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar levels). A record review of Resident #3's MDS assessment, dated 2/25/2026, revealed a [AGE] year-old male who was admitted for long term care for ADL care and colostomy care. A record review of Resident #3's orders revealed, on 3/5/2025, the physician ordered Resident #3 to be cared for under an isolation droplet precaution related to his diagnosed flu infection. An observation and interview on 3/12/2026 at 3:43 PM revealed Resident #3's room door closed and had signage and PPE hung on the door. The PPE supplies included surgical masks, gowns, gloves and a face shield. The signage on the door read Stop Droplet Precautions to prevent the spread of infection anyone entering this room must: hand hygiene, N95 Mask, gloves, gown. NP B entered Resident #3's room and only wore a surgical mask as her PPE. NP B exited Resident #3's room into the hallway without doffing the surgical mask. NP B stated she had not recognized the signage and had not donned the appropriate PPE for Resident #3's isolation droplet precautions. NP B stated she should have also donned a gown and gloves as well as the mask and doffed the PPE immediately prior to exiting the room. NP B stated the potential negative outcome could be the spread of infectious diseases. During an interview on 3/13/2026 at 2:24 PM, the DON stated her expectation for infection prevention and control specific for residents who were under isolation precautions was for all who needed to enter those rooms were to DON and doff PPE as posted and as trained. The DON stated the expectation was for staff to perform hand hygiene, don a surgical mask, gown, and gloves prior to entering an isolation protocol room and to doff the PPE immediately prior to exiting the room. The DON stated the potential negative outcome could be the spread of infectious diseases. A record review of the facility's policy Personal Protective Equipment – Using Gowns dated December 2025 revealed, . To prevent the spread of infections to prevent soiling of clothing with infectious material, to prevent splashing or splattering blood or body fluids onto clothing or exposed skin, and to prevent exposure to the HIV and hepatitis B viruses from blood or body fluids. Obtain the gown, wash hands, unfold the gowns that the opening is at the back, put your arms into the sleeves of the gown, don the gown at the neck, tie at the neck, overlap the gown at the back, be sure clothing is completely covered, secure at the waist, . removing the gown, untie unfasten the back of the gown, remove gloves and discard them into waste receptacle in the room, untie the neckband, while still holding the neck strings pull the gown off the shoulders, remove the gown by rolling it away from the body, handle the inside of the gown only, discard the gown into the waste receptacle inside the room, wash hands, if a mask was used during the procedure or services remove it at this time and discard it into the waste receptacle inside the room, wash hands. 2. Record review of Resident #19's face sheet, dated 03/13/2026, revealed a 101-years-old female, originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident #19 had diagnoses which included heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), urinary tract infection (an infection in any part of the urinary system, such as bladder), and hypertension (high blood pressures). Record review of Resident #19's quarterly MDS assessment, dated 12/01/2025, revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognition was intact. Resident #19 was frequently incontinent to bowel and bladder. Record review of Resident #19's comprehensive care plan, dated 10/10/2024, the resident had the care plan of I have a History of Urinary Tract Infection. For intervention - Obtain vital as ordered/facility protocol. Observation on 03/12/2026 at 12:40 PM CNA-T opened Resident #19's dirty brief to provide incontinent care, cleaned the resident, left the groin area and genital area on separating the area, then turned the resident to side. CNA-T cleaned the resident's buttock area and changed gloves without washing or sanitizing her hands, then put the new brief under the resident. Interview on 03/12/2026 at 12:58 PM with CNA-T said she just changed her gloves without sanitizing or washing her hands after cleaning Resident #19's buttock area. The CNA said she should have sanitized or washed her hands when changing gloves to prevent possible infection. Interview on 03/13/2026 at 2:18 p.m. with the DON said the CNA should have sanitized or washed her hand when changing gloves to prevent possible infection. 3. Record review of Resident #82's face sheet, dated 03/13/2026, revealed a 74-years-old female who was admitted to the facility on [DATE]. Resident #82 had diagnoses which included pulmonary embolism (sudden blockage in a lung artery), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), and dependence on renal dialysis (require dialysis treatment of chronic kidney diseases or acute kidney injury). Record review of Resident #82's admission MDS assessment revealed the assessment was in progress on 03/13/2026 because the resident was admitted to the facility on [DATE]. Record review of Resident #82's baseline care plan, dated 03/07/2026, revealed the resident had the baseline care plans of Infection control intervention to reduce the transmission of multidrug-resistant organisms. Record review of Resident #82's physician order, start dated 03/07/2026, revealed the resident had the order of Weights &Vital signs per facility policy. Observation on 03/12/2026 at 8:22 a.m. revealed MA-M came out from another resident's room with a blood pressure cuff and entered Resident #82's room. MA-M took Resident #82's blood pressure without cleaning the blood pressure cuff. Interview on 03/12/2026 at 8:37 a.m., MA-M said she did not clean the blood pressure cuff and measured Resident #82's blood pressure without cleaning it. The MA-M stated she forgot cleaning it, and she should have cleaned the blood pressure cuff after using it to prevent possible infection. Interview on 03/13/2026 at 2:18 p.m., the DON said the facility did not have a policy regarding cleaning the blood pressure cuff after using it, but the MA-M should have cleaned the blood pressure cuff after using it to prevent possible infection. A record review of the facility's policy Personal Protective Equipment – Using Gowns dated December 2025 revealed, . To prevent the spread of infections to prevent soiling of clothing with infectious material, to prevent splashing or splattering blood or body fluids onto clothing or exposed skin, and to prevent exposure to the HIV (human immunodeficiency virus) and hepatitis B viruses from blood or body fluids. Obtain the gown, wash hands, unfold the gowns that the opening is at the back, put your arms into the sleeves of the gown, don the gown at the neck, tie at the neck, overlap the gown at the back, be sure clothing is completely covered, secure at the waist, . removing the gown, untie unfasten the back of the gown, remove gloves and discard them into waste receptacle in the room, untie the neckband, while still holding the neck strings pull the gown off the shoulders, remove the gown by rolling it away from the body, handle the inside of the gown only, discard the gown into the waste receptacle inside the room, wash hands, if a mask was used during the procedure or services remove it at this time and discard it into the waste receptacle inside the room, wash hands. Record review of the facility policy, titled Perineal/Incontinent care, dated 12/2025, revealed .12. Removed gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team determined an individual may self-administer drugs in a safe practice for 1 of 6 residents (Resident #41) reviewed for administration of medications. The facility did not follow the facility's policy regarding Self-Administration of Medications when Resident #41 administered his nasal spray for allergy by himself. This failure could affect residents who self-administer medications by placing them at risk of not receiving their physician ordered medication treatment to meet their individual needs.The findings included: Record review of Resident #41's face sheet, dated 03/12/2026, revealed the resident was a 77-years-old male, originally admitted on [DATE], and readmitted on [DATE] to the facility with diagnosis of lack of coordination (poor muscle control that causes clumsy movement), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and allergy rhinitis (when a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). Record review of Resident #41's quarterly MDS assessment, dated 02/14/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and required Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity.Record review of Resident #41's comprehensive care plan, dated 02/16/2026, revealed the resident had the care plan of My resident rights will be respected and maintained through the review date. For intervention - Freedom of choice: I have the right to: make my own choices regarding personal affairs, care, benefits, and services, choose your own physician at your own expense or through a health care plan manage your own financial affairs in the leastrestrictive method, or to delegate that responsibility to another person. Record review of Resident #41's physician's order, starting date 02/20/2026, revealed the resident had the order of Nasal Mist Inhalation Aerosol Solution 0.9 % (Sodium Chloride (Inhalant)) 1 puff in nostril one time a day for allergies. Record review of Resident #41's medication administration record from 03/01/2026 to 03/31/2026 revealed the medication of Nasal Mist Inhalation Aerosol Solution 0.9 % (Sodium Chloride (Inhalant)) 1 puff in nostril one time a day for allergies was scheduled at 8:00 am. Record review of Resident #41's medication record from 02/20/2026 to 03/12/2026 revealed there was no evolution form for self-administration of medications and there was no self-administered medication record also. Observation on 03/12/2026 at 7:57 a.m. revealed Medication Aide-M administered morning medications to Resident #41, except Nasal Mist Inhalation Aerosol Solution 0.9 %. Interview on 03/12/2026 at 12:14 p.m. Resident #41 said he administered his Nasal Mist Inhalation Aerosol Solution 0.9 % to each nostril with one puff every day morning by himself, and he did it even when he was in his home. The resident said he wanted to administer the medication by himself, instead of nurses. The resident said nobody evaluated him regarding this medication, and he had this medication in his possession. Interview on 03/12/2026 at 12:21 p.m. Medication Aide-M said Resident #41 said he wanted to administer his Nasal Mist Inhalation Aerosol Solution 0.9 % to each nostril with one puff by himself, so the medication aide told it to nurses, but the medication aide said she could not remember when she told it and who she told it. Interview on 03/12/2026 at 12:17 p.m. LVN-U said nobody reported regarding Resident #41's self-administered medication of Nasal Mist Inhalation Aerosol Solution 0.9 %. The nurse stated if the resident wanted to do it by himself, nurses should have contacted his physician, evaluated his ability to do, and documented it on self-administered medication record, and the nurse said she did not know Resident #41 was administered the medication by himself until the surveyor told her. Interview on 03/13/2026 at 2:18 p.m. the DON said Resident #41 had the right to choose the self-administration of medications and he was able to do self-administration of medications, but the facility should have contacted his physician, evaluated his ability, and documented it on self-administered medication record per the facility policy. However, because of lack of communication between nurses and medication aide, the facility failed to follow the policy, and the failure might affect inaccurate drug administration. Record review of the facility policy, titled Self-Administration of Medications, dated 12/2025, revealed . 5. The staff and practitioner will document their finding and the choices of residents who are able to self-administer mediations. 6. For self-administering medications, the nursing staff will determine who will be responsible (the resident or nursing staff) for documenting that medication were taken. 12. Nursing staff will review the self-administered medication record on each nursing shift and they will transfer pertinent information to the medication administration record kept at the nursing station appropriately noting that the doses were self-administered.

Based on interview and record review, the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 2 (Residents #6 and #54) of 5 residents reviewed for chemical restraint, in that: 1. The facility failed to ensure Resident #6 was prescribed Lorazepam for anxiety, no longer than 14 days PRN (as needed) and no duration. 2. Resident #54 were prescribed lorazepam (a class of prescription benzodiazepine [depressant] medications that slow down the central nervous system to treat anxiety, which are intended for short-term use due to risks of dependency and addiction) to be administered as needed, indefinitely without an end date. This failure could place residents at risk of receiving unnecessary psychotropic medications. A record review of Resident #54's admission record dated 3/11/2026 revealed an admission date of 9/23/2025 with diagnoses which included generalized anxiety disorder and cerebral infarct (stroke; a medical emergency that occurs when blood flow to a part of the brain is blocked or a blood vessel in the brain bursts, preventing oxygen from reaching brain tissue). A record review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 was a [AGE] year-old male admitted for long term care with ADLs. Resident #54 was assessed with a BIMS score of 14 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #54's care plan dated 3/11/2026 revealed, I use as needed anti-anxiety medications related to anxiety . give anti-anxiety medications ordered by physician . anti-anxiety side effects; drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, Lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision . A record review of Resident #54's physician's orders revealed on 10/21/2025 the physician prescribed Resident #54 to receive lorazepam 0.5mg, as needed every 12 hours, indefinitely without an end date. A record review of Resident #54's medication administration record for January and February 2026 revealed Resident #54 had been administered as needed lorazepam medication several times: on 1/3/2026, 1/6/2026, 1/13/2026, and on 2/5/2026. During an interview on 3/12/2026 at 4:00 PM LVN G stated the Medical Director prescribed Resident #54 to receive lorazepam 0.5mg as needed for episodes of anxiety. LVN G stated Resident #54 had been administered the medication several times this year (2026), on 1/3/2026, 1/6/2026, 1/13/2026, and on 2/5/2026. LVN G stated Resident #54's lorazepam order began 10/21/2025 and had no end date for discontinuation. LVN G stated the order should have an end date and limited to 14-days per professional standards. LVN G stated she intended to assess Resident #54 and to report to the Medical Director and ask for an order clarification. During an interview on 3/12/2026 at 4:15 PM ADON H stated she had reviewed Resident #54's medical record and revealed the physician had prescribed an indefinite order of lorazepam for Resident #54 and could not identify where the physician had documented a rational for the indefinite order. ADON stated she was assigned the Pharmacy Services portion of the nursing duties and was responsible for reviewing all antipsychotic orders and would ensure orders which were administered as needed would be presented to the Physician for review to have and end date of no longer than 14-days or an end date longer than 14-days with a documented rationale for the extended end date. ADON stated she had not recognized Resident #54 had an antipsychotic order to be administered as needed without an end date. ADON stated the potential negative outcome for residents who received antipsychotic medications without an end date could be prolonged medication administration without an end date. During an interview on 3/13/2026 at 2:24 PM the DON stated her expectation for prescribed antipsychotic medications which were intended to be administered as needed was for the order to not exceed a 14-day duration. The DON stated all antipsychotic orders were reviewed at a minimum upon the date they were prescribed and monthly. The DON stated she was a member of the Interdisciplinary Team (IDT) which reviewed the orders and ensured antipsychotic medication orders which were intended to be administered as needed had an end date and was initially no longer than 14-days. The DON stated Resident #54's October 2025 order without an end date and was an oversight and the potential negative outcome for residents who received antipsychotic medications without an end date could be prolonged medication administration without an end date. A record review of the facility's Antipsychotic or Neuroleptic Medication Use policy dated December 2025, revealed, . The need to continue as needed orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the as needed order will be indicated in the order. As needed orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication. document and observe, document, and report to the attending physician information regarding the effectiveness of any interventions including anti-psychotic medications. The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting based on assessing the situation why the benefits of the medication outweigh the risks or suspected will confirmed adverse consequences. The findings were: 1. Record review of Resident #6's face sheet, dated 03/13/2026, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (partial muscular weakness that occurs on one side of the bed, while hemiplegia is total paralysis on one side), Alzheimer's disease (progressive disease that destroy memories and other important mental functions), and anxiety disorder (symptoms of intense anxiety or panic that are directly by a physical health problem). Record review of Resident #6's admission MDS assessment, dated 01/23/2026 reflected that she was assessed to have a BIMS score was 4 out of 15 indicating she had severe cognitive impairment. Resident #6 was assessed to not have verbal and other behavioral symptoms. However, Resident #6 was assessed to have psychiatric / mood disorder: anxiety disorder, but Resident #6 was further assessed to not be on an antianxiety medication. Record review of Resident #6's comprehensive care plan, dated 02/01/2026, reflected the resident had the care plan of The resident use PRN (as needed) anti-anxiety medications related to anxiety disorder. For intervention - Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS (effects of a chemical substance, such as a medical drug, that is opposite to what would usually be expected): Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. Record review of Resident #6's physician's orders, start dated 01/20/2026, reflected the resident had the order of LORazepam Oral Tablet 0.5 MG (Lorazepam) - Give 1 tablet by mouth every 4 hours as needed for ANXIETY -Start Date- 01/20/2026. Record review of Resident #6's medication administration record from 03/01/2026 to 03/31/2026 revealed Resident #6 did not receive Lorazepam 0.5 mg. Interview with LVN-G on 03/13/2026 at 9:47 a.m., revealed it was confirmed Resident #6 had an order for Lorazepam oral tablet 0.5 mg for anxiety disorder as needed when the resident had anxiety, but the resident did not receive it because when the resident had anxiety, verbal redirections were effective. Interview with the MDS Coordinator on 03/13/2026 at 10:32 a.m., revealed it was confirmed that because Resident #6 did not receive her Lorazepam oral tablet 0.5 mg as needed for anxiety, the resident's MDS assessment coded as No antianxiety. Interview with the DON on 03/13/2026 at 11:15 a.m., revealed it was confirmed Resident #6 had an order for Lorazepam Tablet 0.5 MG - Give 1 tablet by mouth every 4 hours as needed for ANXIETY, and the order should have only been for 14 days. The DON stated she did not know why the order was written over 14 days and did not have duration, as overuse could place Resident #6 at risk for taking unnecessary medications. The DON said she was responsible for overseeing antipsychotic medications daily and currently monitored it at random, and it might affect Resident #6 by her receiving unnecessary medications without re-evaluations.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 20 Residents (Resident #82) whose records were reviewed. The facility failed to ensure Resident #82's baseline care plan included the resident's dialysis status, wound care, and the use of oxygen. This deficient practice could affect any resident and contribute to residents not having their needs met based on their assessment.The findings were:Record review of Resident #82's face sheet, dated 03/13/2026, revealed that the resident was a 74-years-old female and admitted to the facility on [DATE] with diagnosis of pulmonary embolism (sudden blockage in a lung artery), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), and dependence on renal dialysis (require dialysis treatment of chronic kidney diseases or acute kidney injury). Record review of Resident #82's admission MDS assessment revealed the assessment was in progress on 03/13/2026 because the resident was admitted to the facility on [DATE]. Record review of Resident #82's physician order, start dated 03/07/2026, revealed the resident had the order of [Resident #82] to have dialysis every Monday, Wednesday, and Friday at chair time 2:45 PM - pick up at 1:45 PM. Every shift every and Woundcare: left lower leg: Clean wound using gauze and vashe solution. Allow wound bed to soak with vashe saturated gauze for approximately 5 minutes. Clean with damp vashe gauze for peri-wound 4-6 centimeters beyondwound edges circumferentially (from inside to the outside). Pat dry. Apply xeroform gauze to wound bed, cover with abdominal pad, lightly wrap with kerlix gauze, secure with tape. Daily & if needed/soiled. Every day shift for wound care. Further record review of Resident #82's physician orders revealed there was no physician order related to oxygen. Observation on 03/12/2026 at 10:09 a.m. revealed Resident #82 had 3 liters oxygen per minute via nasal cannular and received wound care from the wound care nurse. Interview on 03/12/2026 at 10:09 a.m. with Resident #82 said she had dialysis on every Monday, Wednesday, and Friday. Record review of Resident #82's baseline care plan, dated 03/07/2026, revealed the resident did not have the baseline care plans of dialysis, wound care, and oxygen. Interview on 03/13/2026 at 9:27 a.m. LVN-U stated Resident #82 was receiving oxygen therapy, dialysis, and wound care since she was admitted to the facility on [DATE]. Interview on 03/13/2026 at 10:35 a.m. the MDS Coordinator stated Resident #82's baseline care plan did not reflect the resident's oxygen therapy, dialysis, and wound care, and it was MDS Coordinator's mistake to make sure the baseline care plan reflect the oxygen therapy, dialysis, and wound care. The MDS Coordinator said Resident #82's baseline care plan should have reflected the resident's oxygen, dialysis, and wound care because Resident #82 was receiving oxygen therapy, dialysis, and wound care since she was admitted to the facility on [DATE], and if the baseline care did not reflect those areas, staff might not provide proper care to the resident. Interview on 03/13/2026 at 2:18 p.m. the DON said the MDS Coordinator should have reflected Resident #82's oxygen, dialysis, and wound care on the resident's baseline care plan because Resident #82 was receiving oxygen therapy, dialysis, and wound care since she was admitted to the facility on [DATE] to make sure the resident received proper care. Record review of the facility policy, titled Care plan - baseline, dated 12/2025, revealed 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident and identify the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 20 Residents (Residents #46 and #4) whose records were reviewed for resident needs. 1. The facility failed to ensure Resident #46's care plan reflected the care for the resident's bowel incontinence. 2. The facility failed to ensure Resident #4's care plan was revised and updated after the resident's gastrostomy feeding tube status was changed from continuous feeding to bolus feeding (a way to send formular through feeding tube using a catheter syringe) only at bedtime. The deficient practice could place residents at risk of not receiving proper care and services.The findings were: 1. Record review of Resident #46's face sheet, dated 03/13/2026, revealed the resident was a-91-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), muscle weakness, and hemiplegia and hemiparesis (partial muscular weakness that occurs on one side of the bed, while hemiplegia is total paralysis on one side). Record review of Resident #46's quarterly MDS assessment, dated 12/22/2025, revealed the resident's BIMS score was 0 out of 15 which indicated the resident had severe cognitive impairment and was dependent (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) to transfer for chair-to-bed and toilet, and the resident was always incontinent to bowel and bladder. Record review of Resident #46's comprehensive care plan, dated 09/09/2024, revealed the resident had the care plan of I have bladder incontinence related to hemiplegia and hemiparesis. For interventions - Observe/document for signs and symptoms related to urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Further record review of the care plan did not have any care related to bowel incontinence. Interview on 03/13/2026 at 9:44 a.m. LVN-G stated Resident #46 was always incontinent to bowel and bladder, so the staff should provide incontinent care to bowel and bladder for the resident. Interview on 03/13/2026 at 10:28 a.m. the MDS Coordinator said Resident #46's comprehensive care plan should have reflected the resident's bowel incontinence care because she was always incontinent of bowel, and missing the bowel incontinence care in the care plan was her mistake and it might affect the resident by not receiving proper care. 2. Record review of Resident #4's face sheet, dated 03/13/2026, revealed the resident was a-90-years-old female and admitted to the facility on [DATE] with diagnosis of cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), dysphagia (difficulty in swallowing), and gastrostomy status (surgical opening into stomach for nutritional support or gastric decompression). Record review of Resident #4's quarterly MDS assessment, dated 01/05/2026, revealed the resident's BIMS score was 3 out of 15 which indicated the resident had severe cognitive impairment and had feeding tube for nutrition. Record review of Resident #4's physician order, started date on 02/27/2026, revealed the resident had the order of Enteral Feed Order at bedtime give 2 bolus (each can 250 cubic centimeters) of Fibrersource 1.2 to provide 600 kilocalories/54gram/protein/404ml free water. Record review of Resident #4's comprehensive care plan, dated 10/08/2025, revealed the resident had the care plan of I require tube feeding related to Dysphagia. Intervention - Fibersource 1.2 at 55ml/hour for 22 hours Flush with 80 milliliters water every 4 hours AND in the morning for Tube Feeding Orders Downtime for 2 hours disconnect at 6am and reconnect at 8am. Interview on 03/13/2026 at 9:22 a.m. LVN-U said Resident #4 was eating foods and medications by mouth, and the physician changed order from continuous feeding to bolus feeding only at bedtime on 02/27/2026. Interview on 03/13/2026 at 10:24 a.m. the MDS Coordinator said Resident #4's comprehensive care plan regarding her feeding tube should have been revised and updated because the resident had bolus feedings only at bedtime, instead of continuous feeding, since 02/27/2026, and it was her mistake. The MDS Coordinator said not updating care plan might affect the resident could not receive proper care.Record review of the facility policy, titled Care plans, comprehensive, dated 12/2025, revealed . 8. The comprehensive, person-centered care plan will describe the servibeing.t are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #37) of 4 residents reviewed for incontinence care. When CNA-V was providing incontinent care to Resident #37 on 03/12/2026, CNA-V cleaned the perineal area with multiple passes of one wipe. The failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.The findings included: Record review of Resident #37's face sheet, dated 03/13/2026, reflected the resident was a [AGE] year-old male originally admitted on [DATE] and readmitted to the facility on [DATE] with the following diagnoses of lack of coordination (poor muscle control that causes clumsy movement), urinary tract infection (an infection in any part of the urinary system, such as bladder), and obstructive and reflux uropathy (urinary tract disorder due to a structural or functional obstruction of urinary flow). Record review of Resident #37's quarterly MDS assessment, dated 01/31/2026, reflected that he was assessed to have a BIMS score was 6 out of 15 indicating he had severe cognitive impairment. Resident #37 was assessed he had indwelling urinary catheter and frequently incontinence to bowel. Record review of Resident #37's comprehensive care plan, dated 11/01/2024, reflected the resident had the care plan of I have Indwelling Catheter related to obstructive and reflux uropathy and bowel incontinence. For intervention - clean catheter and peri-area with each incontinence episode. Observation on 03/12/2026 at 4:13 p.m. revealed CNA-V opened Resident #37's old and dirty brief, cleaned the resident's right and left groin areas, and cleaned the resident's genital area and indwelling urinary catheter with multiple pass of one wipe. The CNA then cleaned the resident's buttock areas. Interview on 03/12/2026 at 4:29 p.m. CNA-V stated when she was providing incontinent care to Resident #37, she cleaned with multiple passes of one wipe when cleaning the resident's penis and buttock area because she was very nervous. CNA-V said she should have used a new wipe with each stroke to prevent infection. Interview on 03/12/2026 at 6:00 p.m. the DON said CNA-V should have used a new wipe with each stroke to prevent infection. Record review of the facility policy, titled Perineal/Incontinence Care, revised 12/2025, revealed . 10. For a male resident: . (3) Continue to wash the perineal area including the penis, scrotum and inner thigh. Do not reuse the same washcloth or water to clean the urethra.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided with such care, consistent with professional standards of practice for 2 (Resident #57 and #82) of 9 residents reviewed for respiratory care. 1. Resident #57's nebulizer mask for breathing treatment was not covered in a plastic bag when it was not being used on 03/10/2026. 2. Resident #82 was receiving oxygen therapy without a physician's order. This failure could place residents at risk of illness, respiratory complications and accidents.The findings included: 1. Record review of Resident #57's face sheet, dated 03/13/2026, revealed the resident was a 100-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of lack of coordination (poor muscle control that causes clumsy movement), atrial fibrillation (irregular and often very rapid heart rhythm), and atherosclerotic heart disease (caused by plaque buildup in arterial walls). Record review of Resident #57's quarterly MDS assessment, dated 01/21/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and the resident was receiving oxygen therapy. Record review of Resident #57's comprehensive care plan, dated 10/15/2025, revealed the resident had the care plan of I have as needed Oxygen Therapy related to history of Ineffective gas exchange. For intervention - OXYGEN SETTINGS: OXYGEN at 2 liter per minute via nasal cannular OR FACE MASK TO MAINTAIN oxygen saturation GREATER THAN 90% FOR short of breath as needed. Record review of Resident #57's physician order, starting date 01/02/2026, revealed the resident had the order of Ipratropium-Albuterol Solution 0.5-2.5 (3) Milligram/3miliiters 3 ml inhale orally every 8 hours as needed for short of breath or Wheezing via nebulizer. Observation on 03/10/2026 at 10:05 a.m. revealed Resident #57 was sleeping on the bed with oxygen 2 liters per minute via a nasal cannular. Further observation revealed there was a nebulizer on the nightstand at the bedside, and the mask connected to the nebulizer was on the nightstand without covering in a plastic bag. Interview on 03/10/2026 at 11:25 a.m. the ADON said Resident #57's mask connected to the nebulizer on the nightstand was not covered in a plastic bag, and it should have been covered in a plastic bag when it was not used to prevent possible infection. Interview on 03/13/2026 at 2:18 p.m. the DON said Resident #57's mask connected to a nebulizer for breathing treatment should have been covered in a plastic bag when it was not used to prevent infection. 2. Record review of Resident #82's face sheet, dated 03/13/2026, revealed that the resident was a 74-years-old female and admitted to the facility on [DATE] with diagnosis of pulmonary embolism (sudden blockage in a lung artery), peripheral vascular disease (reduced circulation of blood to a body part other than the brain or heart), and dependence on renal dialysis (require dialysis treatment of chronic kidney diseases or acute kidney injury). Record review of Resident #82's admission MDS assessment revealed the assessment was in progress on 03/13/2026 because the resident was admitted to the facility on [DATE]. Observation on 03/12/2026 at 10:09 a.m. revealed Resident #82 had 3 liters of oxygen per minute via nasal cannular. Interview on 03/12/2026 at 10:09 a.m. with Resident #82 said she had oxygen since she came to the facility. Record review of Resident #82's baseline care plan, dated 03/07/2026, revealed the resident did not have the baseline care plans of oxygen. Record review of Resident #82's physician order, starting dated 03/07/2026, revealed there was no physician's order related to oxygen. Interview on 03/13/2026 at 9:27 a.m. LVN-U stated Resident #82 was receiving oxygen therapy since she was admitted to the facility on [DATE], and the nurse did not know there was no physician's order regarding the resident's oxygen therapy LVN-U said she would contact the resident's physician and get the order immediately because oxygen should have been administered with the physician's order. Interview on 03/13/2026 at 2:18 p.m. the DON said Resident #82 needed to have oxygen therapy due to her respiratory status, and the DON did not know what reason no physician order regarding the resident's oxygen therapy was, and facility nurse might make mistakes regarding putting the oxygen order into the system. If the resident did not have oxygen order, the resident might have inappropriate care or lack of care. Record review of the facility policy, titled Department (Respiratory Therapy) - prevention of infection, dated 12/2025, revealed . 7. Store the circuit in plastic gag, marked with date and resident's name, between uses.

Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 of 20 residents (Residents #41) reviewed for food and nutrition services. The facility failed to ensure Resident #41's personal refrigerator, located in his room, did not have a small plastic cup that was not dated or labeled. This failure could place the residents at risk for food borne illness.The findings include: Record review of Resident #41's face sheet, dated 03/12/2026, revealed a 77-years-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #41 had diagnoses which included lack of coordination (poor muscle control that causes clumsy movement), Chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and allergy rhinitis (when a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). Record review of Resident #41's quarterly MDS assessment, dated 02/14/2026, revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive was intact. Resident #41 required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating. Record review of Resident #41's comprehensive care plan, dated 02/16/2026, revealed I have a nutritional problem or potential for nutritional problem related to Protein-Calorie Malnutrition. For intervention - Monitor/document/report to physician for signs and symptoms of dysphagia (difficulty in swallowing): Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Observation on 03/10/2026 at 10:11 a.m. revealed in Resident #41's room, there was one small refrigerator. Inside the refrigerator, there was one plastic container with some food, and the container did not have a label and was not dated. Interview on 03/10/2026 at 10:12 a.m., Resident #41 said the resident's family member might bring the food, but he did not know what it was and when the resident's family member would bring it. Interview on 03/10/2026 at 11:27 a.m., the ADON stated in Resident #41's room, there was one small refrigerator. Inside the refrigerator, there was one plastic container with some food, and the container did not have any label or date. The ADON said it looked like chicken salad, and the facility nurses should have labeled and dated the container when the resident's family brought the food from outside to prevent possible food illness, and night nurses should have checked the resident's refrigerator every night. Interview on 03/13/2026 at 2:18 p.m., the DON said the facility nurses should have labeled and dated the container when the resident's family brought the food from outside to prevent possible food illness. Record review of the facility's policy, titled Foods Brought by Family/Visitors, dated 12/2025, revealed . 7. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Container will be labeled with the resident's name, the item and the use by date.

Based on interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices, on each resident that were complete and accurately documented for 1 of 20 residents (Resident #4) reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #4 had physician orders that documented the could have liquid protein supplements by mouth instead of via gastrostomy tube. This failure could place residents at risk for incorrect medication administrations due to misinformation by incomplete and inaccurate medical record. Findings include: Record review of Resident #4's face sheet, dated 03/13/2026, revealed a 90-years-old female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included cerebral infarction (disrupted blood flow to the brain due to problem with the blood vessels that supply it), dysphagia (difficulty in swallowing), and gastrostomy status (surgical opening into stomach for nutritional support or gastric decompression). Record review of Resident #4's quarterly MDS assessment, dated 01/05/2026, revealed the resident's BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Resident #4 had feeding tube for nutrition. Record review of Resident #4's physician order, start date on 09/24/2025, revealed the resident had the order of Liquid Protein in the morning for supplement Give 30milliters every day via gastrostomy tube to provide 15 gram protein/100kilocalories. Further record review of the physician orders revealed the resident was receiving all medications by mouth. Interview on 03/13/2026 at 9:22 a.m., LVN-U stated Resident #4's order of Liquid Protein in the morning for supplement Give 30ml every day via gastrostomy tube to provide 15 gram protein/100kcals was incorrect and inaccurate because the resident was receiving all food and medications by mouth as ordered, and the resident was receiving only bolus feeding via gastrostomy tube at bedtime. The nurse said she did not know what reason the order had still via gastrostomy tube, instead of by mouth. Interview on 03/13/2026 at 2:19 p.m., the DON said Resident #4's order of Liquid Protein in the morning for supplement Give 30 miliiters every day via gastrostomy tube to provide 15 gram protein/100kcals was incorrect and inaccurate because the resident was receiving all food and medications by mouth as ordered. The DON said when the facility nurses changed orders regarding Resident #4's medications from via gastrostomy tube to by mouth, nurses did not change only this order of Liquid Protein in the morning for supplement. The DON stated an inaccurate medical record might affect inaccurate care to the resident due to confusion. Record review of the facility's policy, titled Charting and documentation, dated 12/2023, revealed All services provided to the resident or any changes in the resident's medical or mental conditions, shall be documented in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #3) whose assessments were reviewed. The facility failed to indicate Resident #3 received oxygen on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments. FindingsThe findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed she was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and under Section O it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs sections for blood oxygen saturation revealed on 09/03/2025, 09/05/2025 and on 09/07/2025 she received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. Interview on 09/29/25 at 12:51 PM, the MDS Nurse stated she would look at the resident's entire electronic clinical record and/or their hospital record when the MDS was completed to ensure it was accurate. The MDS Nurse reviewed Resident #3's Quarterly MDS dated [DATE] and stated the oxygen was not checked because she had reviewed the MARs which did not indicate the resident had received oxygen. The MDS Nurse reviewed Resident #3's vital signs section in the electronic clinical record for oxygen saturation and verified Resident #3 received oxygen during the look-back period the MDS was completed and the MDS should have been checked the resident received oxygen. The MDS Nurse stated she was responsible for ensuring the MDS was completed accurately and the harm of not having the MDS completed accurately could result in other health care members not know the resident needed oxygen. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated the MDS Nurse was responsible for ensuring the accuracy of the MDS assessments and the harm of an inaccurate MDS could result inaccurate plan of care for the resident. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated the Executive Clinician and the Corporate MDS Nurse oversaw the residents' MDS assessments to ensure they were accurate and if the MDS assessment was not completed accurately, then the care administered to the resident might not be appropriate for the resident. Record review of CMS's RAI Version 3.0 Manual, dated October 2025, CH 3: MDS Items O, page O-4, revealed under Section O, oxygen should be checked if a resident received oxygen either continuous or intermittent in the past 14 days. Record review of the facility's policy Resident Assessment Instrument, revised December 2024, revealed a comprehensive assessment of a resident's needs shall be made withing fourteen (14) days of the resident's admission. 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews.3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #3) reviewed for respiratory care. Resident #3 received oxygen at 2 liters per minute via nasal cannula without a physician order. This failure could affect residents with oxygen therapy and could lead them to a lack of care. The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed Resident #3 was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness, revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs section for blood oxygen saturation revealed on 09/03/2025, 09/05/2025, 09/07/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/12/2025, 09/14/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025, 09/21/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/27/2025, and 09/28/2025 Resident #3 received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. In an interview on 09/28/25 at 2:44 PM, after LVN A reviewed Resident #3's physician orders, she stated the resident did not have an order for oxygen and Resident #3 should have an order since the resident received oxygen. LVN A stated the harm of not having an order for oxygen could cause respiratory distress if she [the resident] didn't have it [oxygen] or too much [oxygen] could be administered. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated when a resident received oxygen, they should have an order for the oxygen and the harm of not having an order could result in the oxygen treatment not being monitored. The Executive Clinician said she and the ADON were responsible for ensuring the resident's clinical records were accurate and they would review the orders from the hospital when the resident was admitted or readmitted to the facility to ensure the orders were accurate. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated when a resident received oxygen it should be documented in their clinical record, in their plan of care, and there should be an order for the oxygen. The Executive Director stated the harm of not having an order for oxygen was there would not be any documentation that it was ordered by the physician and any treatment would have to have a doctor's order. Record review of the facility's policy Oxygen Administration, revised October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for two (2) residents' (Resident #1 and Resident #2) needs for one (1) of five (5) licensed nurses (the ADON) reviewed for staff competency. 1. While providing wound care for Resident #1 on 11/24/2025, the ADON did not fully cover the resident's wound bed with the calcium alginate dressing per physician order.2. While providing wound care for Resident #1 on 11/25/2025, the ADON did not date or initial the wound dressing.3. While providing wound care for Resident #2 on 11/25/2025, the ADON did not date or initial the wound dressing. These failures could place residents at risk for improper care and complications of residents' medical care.The findings included: 1. Record review of Resident #1's admission Record, dated 11/24/2025, reflected a [AGE] year-old female. She was admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 11/24/2025, revealed diagnoses included enterocolitis (an inflammation that occurs in a person's digestive tract) due to clostridium difficile (a bacterium that causes severe diarrhea), diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 10, indicating she had moderate cognitive impairment. She had a diabetic foot ulcer with an application of dressings to the feet for treatment. Record review of Resident #1's Care Plan Report, undated and electronically accessed 11/24/2025, revealed the following focuses and corresponding interventions/tasks: - Focus: I have Diabetic Ulcer to right heel r/t Diabetes/PVD, date initiated 09/03/2025 and date revised 11/11/2025. - Intervention: Ensure appropriate protective devices are applied to affected areas., date initiated 09/03/2025. - Focus: Resident is at risk for pressure ulcers r/t decreased mobility., date initiated 09/18/2025 and revised 11/11/2025. - Intervention: Administer treatments as ordered and monitor for effectiveness., date initiated 09/18/2025. Record review of Resident #1's Order Summary Report, dated 11/24/2025 at 04:47 p.m. with active orders as of 11/24/2025, revealed the following order:- Cleanse R heel with wound cleanser or normal saline [water with dissolved salt]. pat [sic] dry. Apply santyl [sic; a topical medication used to remove dead tissue from wounds and promote healing] and calcium alginate [a type of wound dressing that absorbs the secretions from a wound and promotes healing] to wound bed and cover with dry dressing. daily [sic] and prn. every [sic] day shift for wound care, order status noted as active and dated 11/24/2025. During an observation and interview on 11/24/2025 at 03:55 p.m., Resident #1 was observed lying in bed with heel protective booties on both feet. She revealed she had had a wound on her right foot for at least a week or two. She stated she was waiting for the nurse to provide treatment for it. She stated she was not concerned about the care provided by the nursing staff. During an observation on 11/24/2025 at 04:34 p.m., the ADON performed wound care for Resident #1. During wound care, the ADON cleansed the wound with wound cleanser and patted dry. She applied the Santyl ointment, followed by the calcium alginate dressing to the wound bed. The calcium alginate dressing was observed not applied to the center of the wound resulting in a visible portion of the medial (towards the center of the body) half of the wound not covered by the calcium alginate dressing. A dry dressing with the date and the ADON's initials was applied over the entire wound. 2. During an observation on 11/25/2025 at 10:34 a.m., the ADON performed wound care for Resident #1. During wound care the ADON was observed to apply the dry dressing to cover the wound. The dry dressing was undated and not initialed. 3. Record review of Resident #2's admission Record, dated 11/25/2025, reflected a [AGE] year-old male. He was admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 11/25/2025, revealed diagnoses included unsteadiness on feet, moderate protein-calorie malnutrition (lack of proper nutrition), colostomy status (an opening in the colon that allows stool to exit the body into a pouch without going through the anus), and stage four pressure ulcer (defined as the most severe form of an injury to the skin and tissue below the skin caused by prolonged pressure on a specific area of the body with full-thickness tissue loss) of sacral region (the triangular region at the base of the spine and just above the buttocks). Record review of Resident #2's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating he was cognitively intact. He had an ostomy (a surgically created opening in the body which may include a colostomy, which is a surgical opening in the intestine allowing organic matter to exit the body without going through the anus), one stage 4 pressure ulcer was present upon admission/entry or reentry, and surgical wound(s). This MDS revealed Resident #2's skin and ulcer/injury treatments included pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings, application of ointments/medications other than to feet, and application of dressings to feet. Record review of Resident #2's Care Plan Report, undated and accessed 11/25/2025, revealed the following focuses and corresponding interventions/tasks: - Focus: Resident c stage IV pressure ulcer to coccyx. Resident is at risk for additional pressure ulcers r/t decreased mobility, malnutrition, & HX of pressure ulcers. State 4 Pressure Ulcer to Sacrum Onset: 8/05/24., date initiated 01/09/2025 and revised 10/22/2025. - Intervention: Administer treatments as ordered and monitor for effectiveness., date initiated 01/09/2025. - Intervention: Monitor dressing (FREQ) to ensure it is intact and adhering. Report lose dressing to Treatment nurse, date initiated and revised 01/09/2025. Record review of Resident #2's Order Summary Report, dated 11/24/2025 at 04:47 p.m. with active orders as of 11/24/2025, revealed the following orders:- Cleanse Coccyx [the tail bone located within the sacrum region] with wound cleanser or normal saline, pat dry, apply Santyl, hydroferablue [an antibacterial foam dressing that promotes healing while preventing infection] cut to fit. cover [sic] with dry dressing Daily and PRN. every [sic] day shift for Wound care, order status noted as active and dated 10/27/2025. During an observation on 11/25/2025 at 10:15 a.m., the ADON performed wound care for Resident #2. During wound care the ADON was observed to apply the dry dressing to cover the wound. The dry dressing was undated and not initialed. During an observation and interview on 11/25/2025 at 10:30 a.m., Resident #2 revealed he was excited to have returned to the nursing facility because his wounds were getting better. He revealed he had no complaints or concerns about the care provided by the nursing staff. During an interview on 11/25/2025 at 11:13 a.m. MD A revealed he was the facility's wound care physician for three (3) months. He stated the first time he made wound care rounds with the ADON he observed her wound care treatments. He stated he had not observed any identified concerns with the ADON's treatments. He stated he had not provided facility staff training on wound care or reviewed the staff competencies for wound care provisions. During an interview on 11/25/2025 at 11:48 a.m., the VPCS stated the facility did not have a policy on nurse competencies. During an interview on 11/25/2025 at 06:06 p.m., the ADON stated a prior ADON was responsible for assessing staff competencies. She did not identify the staff member currently responsible. She stated she was unsure if wound care competencies were part of the competency checks that were performed. The ADON stated the prior wound care nurse completed her competency check in August of 2025. She stated she made rounds with MD A for the past three (3) weeks. She stated she did not realize the calcium alginate dressing did not fully cover Resident #1's wound during the wound care treatment on 11/24/2025. She stated the error could possibly impact the improvement of Resident #1's wound. The ADON stated she did not realize she did not label the dry dressings for Resident #1 and Resident #2 during wound treatments on 11/25/2025. She stated a lack of labeling the dressing with a date and initial could result in another staff member not knowing when the dressing was last changed. During an interview on 11/26/2025 at 07:50 p.m., the VPCS stated she was not familiar with Resident #1's wound and could therefore not determine if or how much not fully covering the wound with the calcium alginate dressing would impact her wound treatment and status. During an interview on 11/26/2025 at 20:09 p.m., the ADMIN stated the expectation for staff to date and initial the wound dressings was for staff to date it immediately after completing the wound treatment so everyone coming after that staff member would know when the next wound care would need to be done. She stated the expectation was very important. Record review of facility document titled Licensed Nurse Competency, signed and dated 07/16/2025, indicated the ADON, hire date 08/15/2022, completed competency trainings and assessments. The document stated Training on the following topics was provided. (*Indicates competence). Under the section titled, Nursing Skills, a subsection titled Skin and Wound Care included: Arterial, diabetic, venous wounds and Pressure ulcer/injury prevention and management. Record review of the facility's policy, Wound Care, dated as reviewed December 2024, reflected: Policy: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Steps in the Procedure. 11. Apply treatments as indicated. 12. Dress wound. [NAME] dressing with initials, time, and date.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (2) of two (2) residents (Resident #1 and Resident #2) reviewed for infection control. 1. The facility failed to post signage on 11/24/2025 to indicate Resident #1 was ordered to be on contact isolation precautions prior to or immediately upon notification of the order. While providing wound care for Resident #1 on 11/24/2025 and 11/25/2025, the ADON did not wash her hands prior to or after providing wound care to a resident who was on contact precautions. The ADON did not sanitize her hands between glove changes. While providing wound care for Resident #1 on 11/25/2025, the ADON placed open wound care supplies directly on the resident's bed. 2. While providing wound care for Resident #2 on 11/25/2025, the ADON did not sanitize her hands between glove changes. These failures could place residents at risk for infection due to improper care practices. The findings included: Record review of Resident #1's admission Record, dated 11/24/2025, reflected a [AGE] year-old female. She was admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 11/24/2025, revealed diagnoses included enterocolitis (an inflammation that occurs in a person's digestive tract) due to clostridium difficile (a bacterium that causes severe diarrhea), diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 10, indicating she had moderate cognitive impairment. She had a diabetic foot ulcer with an application of dressings to the feet for treatment. She had an active diagnosis of pneumonia and received antibiotic medication during the last seven (7) days reviewed or since admission/entry or reentry. Record review of Resident #1's Care Plan Report, undated and electronically accessed 11/24/2025, revealed the following focuses and corresponding interventions/tasks: - Focus: I have Diabetic Ulcer to right heel r/t Diabetes/PVD, date initiated 09/03/2025 and date revised 11/11/2025. - Intervention: Monitor/document/report to MD PRN any s/sx of infection: ., date initiated 09/03/2025.- Focus: Resident has a condition which requires contact isolation. [C-diff], date initiated and revised 09/18/2025. - Intervention: Educate resident and family members on standard precautions., date initiated 09/18/2025. - Intervention: In-service direct care staff on contact isolation techniques, date initiated 09/18/2025. Record review of Resident #1's Order Summary Report, dated 11/24/2025 at 04:47 p.m. with active orders as of 11/24/2025, revealed the following order:- Cleanse R heel with wound cleanser or normal saline [water with dissolved salt]. pat [sic] dry. Apply santyl [sic; a topical medication used to remove dead tissue from wounds and promote healing] and calcium alginate [a type of wound dressing that absorbs the secretions from a wound and promotes healing] to wound bed and cover with dry dressing. daily [sic] and prn. every [sic] day shift for wound care, order status noted as active and dated 11/24/2025.- Resident is on EBP and Standard Precautions R/T wound care- any skin opening that requires a drg.Don [put on] PPE inside the room. every [sic] shift for Enhanced barrier precautions related to medical condition Staff [sic] must don gown &gloves [sic] when performing high contact care such as.dressing changes., order status noted as active and dated 11/17/2025.- Resident is on strict isolation R/T (C-diff). Contact Isolation [sic] Resident will receive all services including but not limited to.treatments and nursing services in their room. every [sic] shift for Isolation medical condition, order status noted as active and dated 11/24/2025. Record review of Resident #1's Progress Note, dated 11/24/2025 for progress notes effective 10/25/2025 to 11/25/2025, revealed:- a progress note dated 11/24/2025 at 02:27 p.m. revealed Resident #1 had a diabetic foot ulcer present on admission. - a progress note dated 11/24/2025 at 03:08 p.m. revealed Resident #1 arrived to the facility by ambulance. During an observation on 11/24/2025 at 03:51 p.m., Resident #1's door was observed to be open with the end of Resident #1's bed and her feet, in heel protective booties, visible from the hallway. Next to the door opening, a sign noted the resident was on enhanced barrier precautions. During an interview on 11/24/2025 at 03:55 p.m., Resident #1 revealed she had just returned, that same day, from the hospital. She stated she had gone to the hospital due to having diarrhea for a week prior to her transfer to the hospital. Resident #1 stated she had wounds on her feet prior to her admission to the facility and thought they were improving. She denied concerns regarding wound care provided by facility staff. She was unaware of contact precautions/ isolation during the interview. During an observation and interview on 11/24/2025 at 04:34 p.m., the ADON stated Resident #1 was on contact precautions for C-diff. The ADON stated the resident was just back from the hospital, that same day, and confirmed the contact precautions signage on the door was not present. The ADON performed wound care for Resident #1. The ADON entered the resident's room, sanitized her hands, put on a personal protective gown, put on gloves, entered the resident's attached restroom to obtain a disposable paper towel, placed the paper towel down on an empty side table located in the resident's room, placed her prepared treatment supplies down on the paper, and closed the resident door. Wearing the same gloves, the ADON removed Resident #1's right heel protective bootie, propped the resident's foot on the bootie, to allow the foot to rest on her lower calf or upper ankle and stay slightly elevated off the bed, and removed the old wound dressing. The ADON removed her gloves and put on new gloves without sanitizing or washing her hands in-between glove changes. She cleansed the wound with wound cleanser and patted dry. She applied the Santyl ointment, followed by the calcium alginate dressing to the wound bed. A dry dressing with the date and the ADON's initials was applied over the entire wound. The ADON reapplied Resident #1's right heel protective bootie and covered the resident's feet with her blanket. The ADON discarded the wound treatment supplies into the resident's trash, collected the resident's trash, and put the side table back toward the center of the room. On the way out of the room, the ADON removed her protective gown and gloves. She was then observed to sanitize her hands. She was not observed to wash her hands. During an interview on 11/24/2025 at 04:47 p.m., the ADON stated the signage for Resident #1's contact isolation was up. During an observation on 11/25/2025 at 10:34 a.m., contact precaution signage was noted outside Resident #1's door. The ADON performed wound care for Resident #1. The ADON entered the resident's room, sanitized her hands, put on a personal protective gown, put on gloves, entered the resident's attached restroom to obtain a disposable paper towel, placed the paper towel down on an empty side table located in the resident's room, placed her prepared treatment supplies down on the paper, and closed the resident door. Wearing the same gloves, the ADON removed Resident #1's right heel protective bootie, propped the resident's foot on the bootie, to allow the foot to rest on her lower calf or upper ankle and stay slightly elevated off the bed, and removed the old wound dressing. The ADON removed her gloves and put on new gloves without sanitizing or washing her hands in-between glove changes. She cleansed the wound with wound cleanser and patted dry. She applied the Santyl ointment. She picked up the packet that contained the calcium alginate dressing and the packet that contained the dry dressing, opened both packets, and placed both open packets directly on the resident's bed, next to the resident's right heal. The calcium alginate dressing, followed by the dry dressing was applied to the wound. The ADON reapplied Resident #1's right heel protective bootie and covered the resident's feet with her blanket. The ADON discarded the wound treatment supplies into the resident's trash, collected the resident's trash, and put the side table back toward the center of the room. On the way out of the room, the ADON removed her protective gown and gloves. She was then observed to sanitize her hands. 2. Record review of Resident #2's admission Record, dated 11/25/2025, reflected a [AGE] year-old male. He was admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #2's Diagnosis Report, dated 11/25/2025, revealed diagnoses included unsteadiness on feet, moderate protein-calorie malnutrition (lack of proper nutrition), colostomy status (an opening in the colon that allows stool to exit the body into a pouch without going through the anus), and stage four pressure ulcer (defined as the most severe form of an injury to the skin and tissue below the skin caused by prolonged pressure on a specific area of the body with full-thickness tissue loss) of sacral region (the triangular region at the base of the spine and just above the buttocks). Record review of Resident #2's admission MDS, dated [DATE], revealed the resident had a BIMS score of 15, indicating he was cognitively intact. He had an ostomy (a surgically created opening in the body which may include a colostomy, which is a surgical opening in the intestine allowing organic matter to exit the body without going through the anus), one stage 4 pressure ulcer that was present upon admission/entry or reentry, and had surgical wound(s). His skin and ulcer/injury treatments included pressure ulcer/injury care, surgical wound care, application of nonsurgical dressings, application of ointments/medications other than to feet, and application of dressings to feet. Record review of Resident #2's Care Plan Report, undated and electronically accessed 11/25/2025, revealed the following focuses and corresponding interventions/tasks: - Focus: I have a condition that requires Enhanced Barrier Precautions. EBP are related to Colostomy & wound care-any skin opening that requires a drg., date initiated 08/05/2024 and revised 09/14/2025. - Intervention: Staff must don gown and gloves after entering the room to provide high contact resident care activities such as .wound care., date initiated 08/05/2024. - Focus: . Resident is at risk for additional pressure ulcers r/t decreased mobility, malnutrition, & HX of pressure ulcers. State 4 Pressure Ulcer to Sacrum Onset: 8/05/24., date initiated 01/09/2025 and revised 10/22/2025. - Intervention: Administer treatments as ordered and monitor for effectiveness., date initiated 01/09/2025. - Intervention: Monitor dressing (FREQ) to ensure it is intact and adhering. Report lose [sic] dressing to Treatment nurse, date initiated and revised 01/09/2025. Record review of Resident #2's Order Summary Report, dated 11/24/2025 at 04:47 p.m. with active orders as of 11/24/2025, revealed the following orders:- Cleanse Coccyx [the tail bone located within the sacrum region] with wound cleanser or normal saline, pat dry, apply Santyl, hydroferablue [an antibacterial foam dressing that promotes healing while preventing infection]cut to fit. cover [sic] with dry dressing Daily and PRN. every [sic] day shift for Wound care, order status noted as active and dated 10/27/2025.- Resident is on EBP and Standard Precautions R/T colostomy, &wound [sic] care- any skin opening that requires a drg.Don [put on] PPE Inside the room. every [sic] shift for Enhanced barrier precautions related to medical condition Staff [sic] must don gown &gloves [sic] when performing high contact care such as.dressing changes., order status noted as active and dated 11/17/2025. During an observation on 11/25/2025 at 10:15 a.m., the ADON performed wound care for Resident #2. After removing Resident #2's prior dressing, the ADON was observed to remove her gloves and put on new gloves without sanitizing or washing her hands in-between glove changes. She proceeded with wound care. On the way out of the room, the ADON removed her protective gown and gloves. She was observed to sanitize her hands. During an observation and interview on 11/25/2025 at 10:30 a.m., Resident #2 revealed he was excited to have returned to the nursing facility because his wounds were getting better. He revealed he had no complaints or concerns about the care provided by the nursing staff. During an interview on 11/25/2025 at 11:13 a.m. MD A revealed he was the facility wound care physician for three (3) months. He stated he was okay with the nurse who was providing wound care to use hand sanitizer between wound care treatments but after three (3) residents, he would want them to wash their hands. He stated for a resident with C-diff, he would expect the staff member to wash their hands. He stated if a nurse put wound care supplies on the bed, it would be okay, and he would not have concerns about infection control unless the resident was on contact precautions. He stated he would prefer the supplies to be on the bedside table. He stated the risk of putting wound care supplies on the bed with a resident that had C-diff was the spores from C-diff could contaminate the supplies. During an interview on 11/25/2025 at 06:06 p.m., the ADON stated the expectation for hand hygiene was for the staff member to wash their hands in between residents or use hand sanitizer. She stated if the resident was on isolation precautions, the staff member was to wash her hands before and after wound care. She stated the impact of not sanitizing or washing their hands would be cross contamination. She stated she did not realize she did not sanitize her hands between glove changes. She stated for Resident #1 she did wash her hands after removing her gown. She stated she went back into the room, wiped the side table, and washed her hands. She stated she thought she washed her hands in Resident #2's bathroom prior to providing wound care to Resident #1 on 11/25/2025. She stated she used hand sanitizer prior to putting on her gloves before providing wound care to Resident #1 on 11/25/2025. During an interview on 11/26/2025 at 07:50 p.m., the VPCS stated a resident's door should have a sign indicating the type of isolation the resident was on. She stated the sign should be on the door when the need for isolation was identified. She stated the sign was a safety measure for the staff and visitors as it would let everyone know what types of PPE required. She stated her expectation was for staff to wash their hands before providing care, when they change gloves, and then following the provision of care. She stated she would have to refer to the facility policy to determine if hand sanitizer was appropriate to be used in place of hand washing before and after care. She stated the impact of not sanitizing or hand washing before, after, and in-between glove changes was that there was always a chance of contamination. She stated it could contaminate the wound or whatever the staff member was doing. During an interview on 11/26/2025 at 20:09 p.m., the ADMIN stated the standard was staff needed to wash their hands. She stated she did not know when sanitizer could be used in the place of hand washing. She stated the risk of inadequate hand hygiene was that there would be some potential infection control issues. She stated the expectation for isolation precautions as for the appropriate signage to be on the door and staff to adhere to the policies. She stated she expected the signage to be posted as soon as a resident arrived in the building and staff had the resident's paperwork. She stated staff would actually already know the condition of the resident prior to their arrival at the facility, so the staff should have the sign posted as part of making the room ready for the resident. She stated the signage should already be up prior to the resident's arrival. She stated the importance of posting the isolation precaution sign was that it alerted staff of the isolation precautions, so staff could prepare. Record review of the facility's policy, Hand-Washing/Hand Hygiene, dated as reviewed December 2024, reflected: Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. 2. All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; . d. Before performing any non-surgical invasive procedures; . f. Before donning sterile gloves; g. Before handling clean or soiled dressings, gauze pads, etc.; . i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.; . m. After removing gloves; n. Before and after entering isolation precaution settings; .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Record review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, dated as reviewed December 2024, reflected: PurposeTo provide guidelines for general infection control while caring for residents.General Guidelines .3. Enhanced Barrier Precautions (EBP).employes targeted gown and glove use during high contact resident care activities.EBP are indicated for residents with any of the following: .Wounds.4. Employees must wash their hands for twenty (20) seconds or longer using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; . c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions;. g. When there is likely exposure to spores (i.e., C. difficile or Bacillus anthracis) (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% chlorhexidine gluconate.)5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; b. Before donning sterile gloves; c. Before performing any non-surgical invasive procedures; . e. Before handling clean or soiled dressings, gauze pads, etc.; f. Before moving from a contaminated body site to a clean body site during resident care; g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; . j. After removing gloves.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #3) whose assessments were reviewed. The facility failed to indicate Resident #3 received oxygen on her Quarterly MDS dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed she was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and under Section O it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs sections for blood oxygen saturation revealed on 09/03/2025, 09/05/2025 and on 09/07/2025 she received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. Interview on 09/29/25 at 12:51 PM, the MDS Nurse stated she would look at the resident's entire electronic clinical record and/or their hospital record when the MDS was completed to ensure it was accurate. The MDS Nurse reviewed Resident #3's Quarterly MDS dated [DATE] and stated the oxygen was not checked because she had reviewed the MARs which did not indicate the resident had received oxygen. The MDS Nurse reviewed Resident #3's vital signs section in the electronic clinical record for oxygen saturation and verified Resident #3 received oxygen during the look-back period the MDS was completed and the MDS should have been checked the resident received oxygen. The MDS Nurse stated she was responsible for ensuring the MDS was completed accurately and the harm of not having the MDS completed accurately could result in other health care members not know the resident needed oxygen. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated the MDS Nurse was responsible for ensuring the accuracy of the MDS assessments and the harm of an inaccurate MDS could result inaccurate plan of care for the resident. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated the Executive Clinician and the Corporate MDS Nurse oversaw the residents' MDS assessments to ensure they were accurate and if the MDS assessment was not completed accurately, then the care administered to the resident might not be appropriate for the resident. Record review of CMS's RAI Version 3.0 Manual, dated October 2025, CH 3: MDS Items O, page O-4, revealed under Section O, oxygen should be checked if a resident received oxygen either continuous or intermittent in the past 14 days. Record review of the facility's policy Resident Assessment Instrument, revised December 2024, revealed a comprehensive assessment of a resident's needs shall be made withing fourteen (14) days of the resident's admission. 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews.3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #3) reviewed for respiratory care. Resident #3 received oxygen at 2 liters per minute via nasal cannula without a physician order. This failure could affect residents with oxygen therapy and could lead them to a lack of care.The findings included: Record review of Resident #3's admission Record dated 09/28/2025, revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Physician Progress Note, dated 09/24/25, revealed Resident #3 was a [AGE] year-old female with a past medical history which included acute respiratory failure with hypoxia (difficulty breathing resulting in low levels of oxygen in the blood), high blood pressure, congestive heart failure (inability of the heart to adequately pump blood in the body resulting in fluid around the heart and lungs) and pneumonia (a type of lung infection) and the resident received supplemental oxygen. Record review of Resident #3's Quarterly MDS Assessment, dated 09/07/2025, revealed a BIMS score of 15 out of 15 which indicated her cognitive skills for daily decision making were not impaired, and it was not checked she received oxygen. Record review of Resident #3's care plan, initiated 06/30/2025, for the focus area of I have oxygen therapy related to ineffective gas exchange, and respiratory illness, revealed under Interventions was to administer oxygen at 2 LPM via nasal cannula (a specialized tube with prongs into the nose that delivers oxygen from an oxygen concentrator) to maintain blood oxygen saturations above 92%. Record review of Resident #3's Physician's Order Summary, dated 09/28/2025, revealed there was no order for oxygen administration. Record review of Resident #3's electronic clinical record vital signs section for blood oxygen saturation revealed on 09/03/2025, 09/05/2025, 09/07/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/12/2025, 09/14/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/19/2025, 09/21/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/27/2025, and 09/28/2025 Resident #3 received oxygen via nasal cannula. Observation on 09/28/2025 at 8:52 AM revealed Resident #3 was in bed and received oxygen at 2 LPM via nasal cannula. In an interview on 09/28/25 at 2:44 PM, after LVN A reviewed Resident #3's physician orders, she stated the resident did not have an order for oxygen and Resident #3 should have an order since the resident received oxygen. LVN A stated the harm of not having an order for oxygen could cause respiratory distress if she [the resident] didn't have it [oxygen] or too much [oxygen] could be administered. In an interview on 09/29/25 at 1:53 PM, the Executive Clinician stated when a resident received oxygen, they should have an order for the oxygen and the harm of not having an order could result in the oxygen treatment not being monitored. The Executive Clinician said she and the ADON were responsible for ensuring the resident's clinical records were accurate and they would review the orders from the hospital when the resident was admitted or readmitted to the facility to ensure the orders were accurate. In an interview on 09/29/2025 at 2:13 PM, the Executive Director stated when a resident received oxygen it should be documented in their clinical record, in their plan of care, and there should be an order for the oxygen. The Executive Director stated the harm of not having an order for oxygen was there would not be any documentation that it was ordered by the physician and any treatment would have to have a doctor's order. Record review of the facility's policy Oxygen Administration, revised October 2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #27, #38, #9, #2, and #49) of 8 residents observed for infection control. 1. The facility failed to ensure Resident #27's Foley catheter bag was not touching the floor twice on 12/03/2024. 2. The facility failed to ensure Resident #38's Foley catheter bag was not touching the floor on 12/03/2024. 3. The facility failed to ensure Resident #9's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 4. The facility failed to ensure Resident #2's Foley catheter bag was not touching the floor on 12/03/2024 and on 12/05/2024. 5. The facility failed to ensure Resident #49's Foley catheter bag was not touching the floor on 12/06/2024. These failures could place residents at risk for cross contamination, urinary tract infections, hospitalization , resulting in a decline in well-being. Findings included: 1. Record review of the Face Sheet printed on 12/06/2024 reflected Resident #27 was a [AGE] year-old female originally admitted on [DATE]. Record review of the Diagnosis Report printed on 12/06/2024 reflected Resident #27 had the following diagnoses: Parkinson's Disease [movement disorder of the nervous system that worsens with time], stage 4 pressure injury to right lower back and sacral region [back and buttocks area], and malignant neoplasm [cancerous tumor] of anus. Record review of the comprehensive MDS assessment dated [DATE], reflected Resident #27 had a BIMS summary score of 15, indicative of intact cognition. Resident #27 had an indwelling catheter. Record review of the Care Plan printed on 12/06/2024, reflected Resident #27 had an indwelling catheter related to stage 4 pressure injuries to scrum[sp] and right ischium; however, the CP did not include interventions for the care or management of the Foley Catheter. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #27 had physician's orders for Foley Catheter 16 French with 10 ml balloon for pressure injury with a start date of 12/02/2024. In an observation on 12/03/2024 at 10:30 AM, Resident #27 was observed with the Foley catheter drainage bag sitting on the floor. In an observation and interview on 12/03/2024 at 2:38 PM, Resident #27 was observed with the Foley catheter drainage bag sitting on the floor. Resident #27 stated she has had the catheter for a long time. 2. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #38 was a [AGE] year-old female, admitted on [DATE]. Resident #38's BIMS summary score was 11, indicative of moderately impaired cognition. Resident #38's active diagnoses included: renal insufficiency, renal failure, or end-stage renal disease [kidneys are not functioning at their full capacity], and neurogenic bladder [muscles in the bladder wall do not contract and relax properly, causing problems with urination]. Resident #38 was coded as having an indwelling urinary catheter. In an observation on 12/03/2024 at 10:50 AM Resident #38 was observed with the Foley catheter bag touching the floor. 3. Record review of the Face Sheet printed 12/06/2024 reflected Resident #9 was a [AGE] year-old female originally admitted on [DATE]. Record review of the Diagnosis Report, printed on 12/06/2024 reflected Resident #9 had the following diagnoses: Stage 4 pressure injury of the left lower back and sacral region, and type 2 diabetes mellitus. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #9 did not have a BIMS conducted due to being rarely/never understood, with short-, and long-, term memory problems, and moderately impaired cognitive skills for daily decision making. Resident #9 was coded as having an indwelling urinary catheter. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #9 had a physician's order for Foley Catheter, 18 French [indicative of the size of the tubing] with 10 ml NS balloon [10 ml normal saline filled balloon holds the tubing inside the bladder] for patency every shift, with an order date of 10/10/2024. Additional orders included: keep the urinary drainage bag below the level of the blader at all times every shift and as needed, with an order date of 8/13/2024. Record review of the Care Plan printed 12/04/2024 reflected Resident #9 had a focus area of I have indwelling catheter related to pressure injury to left ischium and sacrum, stage 4; with the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door. [CP did not address keeping the Foley catheter bag off the floor.] In an observation on 12/03/2024 at 1:09 PM, Resident #9 was seated in an extra tall-backed wheelchair, being assisted with her meal in the dining room. The Foley catheter bag was hooked under the seat of the extra tall-backed wheelchair too low resulting in it dragging on the floor. In an observation on 12/05/2024 at 12:38 9M Resident #9 was observed with the Foley catheter bag touching the floor. 4. Record review of Resident #2's face sheet, dated 12/06/2024, reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (condition that affects one side of the body usually caused by a stroke that can cause paralysis), a traumatic brain injury, and a cerebral infarction (stroke). Record review of Resident #2's Comprehensive Person-Centered Care Plan, undated, reflected that Resident #2 had a suprapubic catheter related to obstructive & reflux uropathy & BPH with no interventions related to preventing the catheter bag from dragging on the floor. Record review of Resident #2's quarterly MDS assessment, dated 9/28/2024, reflected a BIMS score of 13, indicating that the resident's cognition was intact. The MDS assessment further reflected that Resident #2 utilized an indwelling catheter. Record review of Resident #2's Order Summary Report, dated 12/06/2024, reflected an order which read, Keep urinary drainage bag below the level of the bladder at all times. In an observation on 12/03/2024 at 1:29 PM Resident #2's Foley catheter bag was observed to be dragging on the floor under his wheelchair while being assisted from the dining room back to his room. In an observation on 12/05/2024 at 8:58 AM Resident #2 was observed with the Foley catheter bag touching the floor under his wheelchair while in the communal hallway to the therapy gym. 5. Record review of the Face Sheet printed 12/06/2024 reflected Resident #49 was a [AGE] year-old male originally admitted on [DATE]. Record review of the quarterly MDS dated [DATE], reflected Resident #49 had a BIMS summary score of 11, indicative of moderately impaired cognition. Resident #49 was coded as having an indwelling catheter. Active diagnoses included: obstructive uropathy [blockage of urinary flow], and cerebrovascular accident [loss of blood flow to part of the brain, stroke]. Record review of the Order Summary Report printed 12/06/2024 reflected Resident #49 had a physician's order for Foley catheter, 16 French [indicative of the size of the tubing] with 30 ml balloon [30 ml of fluid filled balloon holds the tubing inside the bladder] with an order date of 11/20/2024. Record review of the Care Plan printed 12/06/2024 reflected Resident #49 had a focus area of I have indwelling catheter related to obstructive and reflux uropathy and BPH ; with the following interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door. [CP did not address keeping the Foley catheter bag off the floor.] In an observation on 12/06/2024 at 10:20 AM Resident #49 was seated in his wheelchair with the Foley catheter attached to wheelchair, with the drainage bag making contact with the floor. In an interview on 12/03/2024 at 1:35 PM LVN B stated the Foley catheter bags should not drag on the floor as it could be a risk to the residents. LVN B stated Foley catheter bags should be under the wheelchair, but not to where they drag on floor. LVN B stated the bag could leak due to friction or be a source of infection . In an interview on 12/06/2024 at 11:07 AM LVN E stated the Foley catheter bag should be positioned on the wheelchair on the left side at the front, where there was a stabilizing bar that was good to hook the Foley Catheter. LVN E stated that when the Foley catheter was placed on the cross bar [underneath the seat of the wheelchair], the Foley catheter bag would slide down to the lowest point of the X and then touch the floor. LVN E stated that staff were trained that the Foley catheter bag should always be lower than the level of the bladder and not glide on the floor due to infection control. LVN E stated this information was trained in annual competencies and in-services frequently . In an interview on 12/06/2024 at 11:16 AM, the DON stated none of the current residents who had Foley catheters self-managed their Foley catheters or the drainage bag. The DON stated it was her expectation that staff ensure the Foley catheter bag was kept below the level of the residents' bladder and not touch the floor for infection control prevention. The DON stated this requirement was trained upon new hire on boarding, at annual competencies, and during in-servicing trainings as necessary. The DON stated that the staff assisting the resident with a Foley Catheter bag was responsible for ensuring that it was not touching the floor. The DON stated that any staff member who saw a Foley Catheter bag touching the floor should either self-correct or alert the appropriate care giver if that staff member was not a direct care giver such as a nurse, CNA, or other clinician. In an interview on 12/06/2024 at 11:38 AM Lead CNA G stated that Foley catheter bags should have covers for privacy, Foley catheter bags should be maintained at a level lower than the bladder, but not touch the floor due to infection control concerns. Lead CNA G stated that she or another lead trained new hires, and she recommended that the Foley catheter bag be hooked towards the front of the wheelchair, as the cross bar at the back and under the seat was too low and the bag could drag on the floor. Lead CNA G stated this procedure was trained upon at hire, at annual competency check offs, and as in-services PRN. Lead CNA G stated that she did random spot checks to ensure the Foley catheter bags were positioning correctly and if not, she would offer immediate counseling to fix it. Lead CNA G stated she was not aware that any Foley catheter bags were reported as touching the floor recently. In an interview on 12/06/2024 at 11:48 AM CNA H stated the Foley catheter drainage bag was always to be placed below the level of the resident's waist to prevent back flow. CNA H stated the Foley catheter bag should be hung on the side of the wheelchair, where it would not fall or drag on the floor. CNA H stated the Foley catheter bag could degrade and leak or could pick up germs from the floor. Review of policy entitled Catheter Care, Urinary, reviewed December 2023, reflected instructions under the heading Infection Control 2b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of Lippincott procedures, Indwelling urinary catheter (Foley) care and management, revised 11/17/2024, accessed from https://procedures.lww.com/lnp/view.do?pId=4420099&hits=care,catheter,catheters,carefully&a=true&ad=false&q=catheter%20care, accessed on 12/05/2024, reflected under the heading Clinical Alert, instructions to keep the drainage bag below the level of the patient's bladder; however, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter associated urinary tract infection.