Every finding on record at Garnet Hill Rehabilitation and Skilled Care

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 7 (Residents #1, #2, #3, #4, and #5) reviewed for pharmacy services.1. The facility failed to ensure Resident #1 was not administered a discontinued medication when she was administered the anti-anxiety medication, lorazepam 0.5 mg, on 05/29/26 after it had been discontinued on 04/30/26. 2. The facility failed to ensure accurate documentation and proper administration for the use of Compound ABH Gel for Resident #2 (06/02/26, 06/04/26, 06/08/26, 06/10/26, 06/11/26) and the use of Clonazepam 0.5 mg for Resident #3 on 06/02/26. 3. The facility failed to document the administration of controlled medications in a timely manner for Residents #4 and #5.These failures could place residents at risk for medication error, drug diversion, and delay in medication administration.Findings included: 1. Review of Resident# 1's Annual MDS Assessment, dated 05/20/26, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included anxiety disorder and hypertension (high blood pressure). The resident's cognition was severely impaired with a BIMS score of 4. She received antianxiety and antidepressant medications.Record review of Resident #1's physician orders revealed Resident #1 did not have an active order for lorazepam 0.5 tablet given 1 tablet by mouth every 8 hour(s) as needed. The record reflected the lorazepam had been discontinued on 04/30/26. Observation and record review on 06/11/26 at 9:45 a.m. with LVN A, of the Hall 400/Hall 500 nurses' medication cart and the NAR revealed Resident #1's NAR for lorazepam 0.5 mg tablet was last signed off on 05/29/26 for one-tablet given to Resident #1 at 4:00 PM. The NAR reflected there were 17 pills remaining, and 17 pills were in the blister pack.Record review of Resident #1's May 2026 MAR revealed no order for lorazepam 0.5 tablet give 1 tablet by mouth every 8 hour(s) as needed. Also, there was no documentation on the MAR showing that lorazepam 0.5 mg had been administered to Resident #1 at 4:00 PM on 05/29/26. During an observation on 06/11/26 at 9:55 a.m., Resident #1 was in her room, and she stated she received all her medications. Resident #1 was unable to recall which medications she was being administered.During an interview on 06/11/26 at 2:14 p.m., LVN A stated she was the nurse assigned to Resident #1. She stated Resident #1 had an order for PRN Lorazepam 0.5 mg. LVN A reviewed Resident #1's MAR and NAR. She stated on the NAR the medication was signed off on 05/29/26 as administered, but the MAR did not show it was administered and Resident #1 did not have the order for the lorazepam. LVN A stated on the NAR, it looked like her signature, but she was not sure. LVN A stated she was not aware Resident #1's PRN Lorazepam medication was discontinued on 04/30/26. She stated the medication and the NAR should had been removed from the medication cart. LVN A stated she did not know why the medication was not removed from the medication cart when the medication was discontinued. She stated it was the responsibility of the nurse to remove any medication from the medication cart that had been discontinued. She stated there should be an order before administering any medication and the nurses should be checking the orders before administering. LVN A stated the potential risk would be the incoming nurse not knowing when the medication was given to the resident. LVN A stated that without a physician order, nurses should not be administering any medication to the residents.2. Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included non-traumatic brain dysfunction. The resident's BIMS was not completed due to resident being rarely/never understood. She received antianxiety and antidepressant medications.Record review of Resident #2's physician order dated 11/11/25 revealed an order for Compound ABH Gel for generalized anxiety disorder 0.5 ml which was to be applied topically once daily at 9:00 AM to the resident's inner wrist.Observation and record review on 06/11/26 at 10:46 a.m., with LVN B of the Hall 200/Hall 300 nurses' medication cart and NAR the revealed Resident #2's NAR for the Compound ABH GEL was last signed off as being administered on 06/09/26. The NAR reflected that 1 dose given to Resident #2 at 8:00 AM, for a total of 4 gels remaining, and there were 4 syringes of the Compound ABH Gel on the nurses' medication cart. There was no documentation on the NAR showing that the Compound ABH Gel had been administered to Resident #2 on 06/02/26, 06/04/26, 06/08/26, 06/10/26, and 06/11/26.Record review of Resident #2's June 2026 MAR revealed Resident #2 was administered Compound ABH gel on 06/02/26, 06/04/26, 06/08/26, 06/10/26, and 06/11/26.Observation on 06/11/26 at 12:32 p.m. revealed Resident #2 was in bed, and she was unable to answer any questions. The resident did not display any signs of agitation or pain.Record review of Resident #3's Quarterly MDS assessment dated [DATE], reflected the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included non-traumatic brain dysfunction. The resident's BIMS was not completed due to resident is rarely/never understood. He received antianxiety medications.Record review of Resident #3's physician order dated 01/20/25 revealed an order of Clonazepam 0.5 mg tablet 1 tablet via Gastrostomy Tube Twice a day [Time: 08:00 AM, 07:00 PM]. Observation and record review on 06/11/26 at 10:46 a.m., of the 200, 300 Hall LVN's medication cart and the narcotic administration record, with LVN B, revealed Resident #3's NAR for Clonazepam 0.5 mg tablet was not signed off as being administered on 06/02/26. The NAR reflected there were 9 pills remaining, and there were 9 pills observed in the blister pack. Record review of Resident #3's June 2026 MAR revealed Resident #3 was administered the clonazepam tablet on 06/02/26 at 8:00 AM. 3. Record review of Resident #4's Quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included anxiety disorder. The resident had intact cognition with a BIMS score of 14. He received antianxiety medication.Record review of Resident #4's physician order dated 01/03/25 revealed Lorazepam 0.5 mg tablet 1 tab by mouth every 4 Hours as needed for anxiety or agitation. Observation and record review on 06/11/26 at 10:46 a.m., of 300 Hall LVN's medication cart and the narcotic administration record, with LVN B, revealed Resident #4's NAR for lorazepam 0.5 mg tablet was signed off as being administered on 06/01/26 at 8:00 AM and 06/10/26 at 8:00 AM. The NAR reflected there were 36 pills remaining, and 36 pills were observed in the blister pack.Record review of Resident #4's June 2026 MAR revealed, for the dates of 06/01/26 and 06/10/26, the MAR was blank. There was no record for the administration of the lorazepam on 06/01/26 and 06/10/26 to Resident #4. During an interview on 06/11/26 at 12:34 p.m., Resident #4 stated he was doing well. Resident #4 stated he received all of his medications. He was unable to state which medications he was receiving. Record review of Resident #5's admission MDS assessment dated [DATE], reflected the resident was [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included hypertension, thyroid disorder, and benign prostatic hyperplasia. The resident had intact cognition with a BIMS score of 15. He received PRN pain medication regimen.Record review of Resident #5 physician order dated 05/07/26, revealed Hydrocodone Bitartrate-Acetaminophen for Pain, unspecified for Pain ([START 05/07/26] 1 TABLET by mouth Every 6 Hours as needed)Observation and record review on 06/11/26 at 2:42 p.m., of 600 Hall RN's medication cart and the narcotic administration record, with RN D, revealed Resident #5's NAR for Hydrocodone-Acetaminophen 5-325 mg was signed off as being administered on 06/02/26 at 8:00 PM. The NAR reflected there were 12 pills remaining, and 12 pills were observed in the blister pack.Record review of Resident #5's June 2026 MAR revealed the MAR was blank for 06/02/26.During an observation and interview on 06/11/26 at 3:57 p.m., Resident #5 was in his room. He stated he received his pain medication when he requested it, and he denied being in any pain. During an interview on 06/11/26 at 1:37 p.m., LVN B stated he was the nurse assigned to Resident #2, Resident #3 and Resident #4. He stated he administered medications to Resident #2, Resident #3 and Resident #4. LVN B stated Resident #2 had an order for ABH Gel 1 time a day. LVN B reviewed Resident #2's MAR and NAR, he stated there was a discrepancy. LVN B stated Resident #2's MAR showed that medication was administered for the following days: 06/02/26, 06/04/26, 06/08/26, 06/10/26, 06/11/26. However, the medication was not signed off on the NAR for those days. LVN B stated he could not recall if the medication was administered. LVN B stated Resident #3 was at the hospital since 06/09/26. He stated Resident #3 had an order for clonazepam 0.5 mg tablet twice a day. LVN B reviewed Resident #3's MAR and NAR. He stated LVN C administered the medication on 06/02/26, but did not sign off the medication on the NAR. LVN B reviewed Resident #4's MAR and NAR. He stated on the NAR for Lorazepam 0.5 mg, he signed off the medication on 06/01/26 and 06/10/26, but did not document on the MAR that the medication was administered. LVN B stated he did administer the medication, but forgot to document that it was administered. He stated after he administered the medication, he should have documented on the MAR in a timely manner. LVN B stated it was important to document when medication was administered, sign the medication out for accountability, and to make sure the next nurse knew when the medication was administered. He stated the potential risk to the residents would be residents receiving double dose. During an interview on 06/11/26 at 1:56 p.m., LVN C stated she was the nurse assigned to Resident #2 and Resident #3 on 06/02/26. She stated she administered medications to both residents. LVN C reviewed Resident #2's MAR and NAR. She stated she documented on 06/02/26 that she administered ABH Gel on 06/02/26, however, she did not sign off the medication on the NAR. She stated she did not think she administered the ABH Gel to Resident #2 on 06/02/26. LVN C stated she did not know why she did not administer it. She stated it was her first time working with Resident #2, a lot was happening on that day, and she did not ask for help. LVN C reviewed Resident #3's MAR and NAR. She stated she documented that she administered Clonazepam 0.5 on 06/02/26 but did not sign off the medication on the NAR. She stated she could not recall if she did or did not administer the medication. LVN C stated if she had given the medications, she would had signed off the medication on the NAR. She stated it was important to document correctly. She stated depending on the medication, the potential risk would be the resident having an adverse effect. During an interview on 06/11/26 at 2:51 p.m., RN D stated she was the nurse assigned to Resident #5. She stated Resident #5 had a PRN order for hydrocodone. RN D stated she administered medication to Resident #5. RN D reviewed Resident #5's MAR and NAR, she stated she was not the nurse assigned to Resident #5 on 06/02/26. She stated on the resident's NAR, the nurse signed off the medication on 06/02/26, however, the nurse failed to document on the resident's MAR. RN D stated she was aware of the discrepancy because she also failed to document Resident 5's MAR for the month of May. She stated she was in-serviced about signing off controlled medication on the count sheet and MAR. She stated she could not recall the date of the in-service. She stated the potential risk of not documenting on the MAR in a timely manner would be incoming staff not knowing when the medication was given, and that could cause an overdose. During an interview on 06/11/26 at 4:21 p.m., the ADON stated the expectation was for the nurses to document on the resident's MAR after administering the medication and to sign off the medication on the NAR. She stated she was not aware the nurses were not documenting on the residents MAR or signing off the medication on the NAR. She stated she used to complete audits with the old system, but with the electronic record system it made it harder to audit. She stated when a medication was discontinued, it should be removed from the medication cart and not be administered. She stated nurses should have an order before administering any medication. She stated it was the ADONs responsibility for overseeing the nurses and ensuring documentation was accurate. ADON stated if it was not documented, it was not done. She stated the potential risk of not documenting correctly would be the staff not able to know if the medication was effective. During an interview on 06/11/26 at 4:35 p.m., the DON stated, during the end of May, she found some discrepancies on the residents' MAR and NAR. She stated she noticed that the nurses were not signing off the medications on the NAR and were not documenting on the residents MAR that the medication had been administered. She stated she completed a full medication cart audit, and all the controlled medications were accounted for, nothing was missing. She stated she was not aware that the nurses were not documenting correctly until she noticed it. The DON stated she completed an in-service on 06/01/26 which covered controlled medications needing to be signed off on both the MAR and the count sheet, and ensuring all expired medications were to be removed from the cart. The DON stated she was made aware that nurses were still not documenting correctly. She stated she had not completed her education, and she had not been able to establish a process for monitoring to ensure the nurses were following procedures. She stated there were several residents who had PRN medications and were not documented when administered. She stated nurses should be removing discontinued medication from the medication cart, and should have an order before administering any medication. She stated it was her and the ADON's responsibility to oversee the nurses and to ensure documentation was accurate. She stated the potential risk of not administering the medication correctly or not documenting in a timely manner, could cause the resident to be in pain, have anxiety, or get the medication more than once. During an interview on 06/11/26 at 5:02 p.m., the Administrator stated she was notified by the DON a week ago that she had found some discrepancies on the residents MAR and narcotic count sheets. She stated the DON started education on it about 2 weeks ago. She stated it was the responsibility of the DON and ADON to oversee the nurses and ensure medications were being administered correctly. She stated there should be a physician order before administering any medication, and nurses should sign off any controlled medication on the NAR and document on the MAR accurately.Record review of the facility's Training Record dated 06/01/26, reflected All controlled medications need to be signed off on both the MAR and the count sheet. To re-iterate previous in-service, please make sure that [you] are signing off any controlled meds on the count sheet legibly, with (at minimum) first initial and last name. Please make sure that all expired medications are removed from the cart. If there are medications that are not being used (or regularly refused), please bring to the attention of the ADON so that those medications can be discontinued. LNV A, LVN B, LVN C, and RN D attended the training. Record review of the facility's Medication - Guidelines on Clinical Practice reviewed 01/12/2020 reflected the following: Standard of Practice: Staff will provide medications in accordance with standard of practice guidelines. Record review of the facility's Physician orders - Electronic reviewed 11/27/23, reflected the following: The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.3. The electronically entered order will be automatically transcribed onto the Medication admission Record (MAR) or Treatment Record. Date and initials of the transcriber will be automatically recorded.9. Upon discontinuation of any medication, the medication is to be removed from the med cart of treatment cart and returned to the pharmacy per the community's policy.

Based on interview and record review, the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #2) reviewed for unnecessary medications. The facility failed to ensure a gradual dose reduction was considered for Resident #2's antidepressant, trazadone, in January 2026 after she began the medication in July 2025. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. Findings include: Record review of Resident #2's Quarterly MDS Assessment, dated 03/03/26, reflected she admitted to the facility on [DATE]. Resident #2 had a BIMS score of 11, which indicated mild cognitive impairment. Resident #2's active diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent fear or worry that interferes with daily life and is difficult to control), paraplegia (a specific pattern of paralysis that affects the legs, resulting from a problem with the nervous system), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Resident #2 was noted to have taken antianxiety, antidepressant, and anticonvulsant medications. Resident #2 had not completed any GDR's for her medications. Record review of Resident #2's, undated, care plan reflected the following: Problems/Strengths: Medication: Potential for discomfort and side effects related to the use of Antidepressant. Resident takes.trazodone [sic]. Interventions: Physician to review medication.Monitor Duration- Prior to discontinuation may need a gradual dose reduction or tapering to avoid a withdrawal syndrome. Record review of Resident #2's progress notes for September 2025, October 2025, and January 2026 did not reflect a GDR was attempted nor was the medication reviewed for a GDR. Record review of Resident #2's April 2026 Physician Orders reflected the following order:Trazodone Hydrochloride 100 MG, 1 tab by mouth at bedtime for Insomnia with a start date of 07/31/25. Record review of Resident #2's April 2026 Medication Administration Record reflected she received her dose of trazodone as ordered each day. Record review of Resident #2's Recommendations for Doctor, dated 01/16/26, reflected the following: Resident is currently prescribed sedative/hypnotic Trazodone [sic] for the treatment of Insomnia since 7/25. According to CMS guidance under F605 (Chemical Restraints). 'For any resident who is receiving a psychotropic medication, the facility must show evidence that a gradual dose reduction has been attempted unless clinically contraindicated.' Please consider a trial dose reduction: If a GDR attempt is not indicated at this time, please indicate reasoning below. There was not an additional document where the provider responded or reviewed the recommendation. During an observation and interview on 04/21/26 at 10:30 a.m., revealed Resident #2 was in bed completing an activity. Resident #2 said she did not want anyone to change her medications because she liked what she was already receiving. Resident #2 said she had no concerns about the medications she received. During an interview on 04/23/26 at 11:29 a.m., the NP and Physician, who were present on the phone only, said the NP was at the facility 4-5 times per week. The NP said Resident #2's GDR review for her trazadone was denied because the resident refused to have any changes to her medications since she felt those medications were working well for her. The Physician said there was likely not a concern with Resident #2's trazadone not being reviewed for a GDR since there were not changes made for her. Interview on 04/23/26 at 12:16 p.m., the DON said GDR's were considered for residents every 90 days. The DON said the facility held a meeting and any necessary medications were reviewed for a GDR. The DON said if a GDR was not considered timely that would put the resident at risk of being on a medication long term that might not be good for them. The DON said the purpose of considering a GDR for a resident was to make sure residents were not on a medication that could contribute to a decline for them. Record review of the facility's Psychotropic Drugs policy, revised 07/27/22, reflected: .3. B. for drug therapy: Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: GDR attempts in two separate quarters with at least one month in between the attempts. The GDR must be attempted annually thereafter unless clinically contraindicated.

Based on observation, interview and record review the facility failed to ensure residents received proper treatment and care to maintain good foot health by providing foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 16 (Resident #83) reviewed for foot care. The facility failed to ensure foot care, specifically trimming of toenails, was provided for Resident #83. This failure could place residents at risk for poor personal hygiene, odors and a decline in their quality of life . Findings include:Record review of Resident #83's significant change in status MDS Assessment, dated 03/24/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #83 had diagnoses which included Non-Alzheimer's Dementia (problems with memory and thinking), anxiety disorder (excessive fear or worry about a specific situation), and heart failure. Resident #83's BIMS score was 06, which indicated severe cognitive impairment. Section GG - Functional Abilities indicated the resident required substantial/maximal assistances from staff to assist with getting personal hygiene. Resident #83 did not have a diagnoses of diabetes. Record review of Resident #83's care plan, dated 04/23/26, revealed Problems/Strengths: Activities of Daily Living-dependent with all activities of daily living. Goals: Improve or maintain care needs and daily living tasks. Interventions Assist with daily care needs and daily living tasks. Encourage to do as much as possible for self.During an observation and interview on 04/21/26 at 1:37 p.m., revealed Resident #83 was sitting in her wheelchair in a room. Resident #83 stated her only concern was her toenails. The big toenails for both of the resident's feet were approximately an inch past the tip of the toe curved to the side. The other toes nails were approximately a quarter of an inch past the tip of the toe. Resident #83 stated she had been asking staff to trim them or to have podiatry come because she did not like seeing her toenails that long. Resident #83 stated the nurses would tell her that they were not able to cut them and she needed to be seen by podiatry. She stated no one followed up with her regarding podiatry. During an interview on 04/23/26 at 12:09 p.m. CNA B revealed the nurses were responsible for trimming residents' fingernails and toenails. CNA B stated she was aware of Resident #83 toenails being very long and needed to be trim. She stated the nurses were aware of how long Resident #83's toenails were. CNA B stated she was not sure if Resident #83 was being seen by podiatry. CNA B stated she was not sure why Resident #83's toenails had not been trimmed. During an interview on 04/23/26 at 12:11 p.m., LVN A revealed she was aware of Resident #83's toenails being long. She stated she received report about a week ago from previous shift regarding Resident #83 wanting her toenails trimmed but the nurse was unable to trim them due to the thickness of the nails. LVN A stated last week during morning meeting it was reported that Resident #83 needed to be referred to podiatry. LVN A stated the social worker was aware of the referral. She stated the potential risk of not trimming toenails could lead to skin breakdowns or infections. During an interview on 04/23/26 at 12:19 p.m., the Social Worker revealed approximately 6 months ago the facility changed podiatrist. She stated Resident #83 was being seen by the old podiatrist but not the new one. She stated the last time Resident #83 was seen by podiatry was about 6 months ago. The Social Worker stated she was not sure why Resident #83 was not being seen by the new podiatrist. She stated Resident #83 requested to be seen by the podiatrist today (04/23/26), and she had just completed the referral. The Social Worker stated prior to Resident #83's request she had not been notified the resident needed to be referred to podiatry. She stated she attended morning meeting and could not recall anyone mentioning Resident #83 needed a podiatry referral. The Social Worker stated either during morning meetings or the nurses would notify her which resident needs to be referred to podiatry. She stated it was her understanding if the resident was not being seen by podiatry, then the nursing staff were responsible for trimming toenails unless the resident was diabetic. During an interview on 04/23/26 at 3:31 p.m., ADON F revealed Resident #83 was known to refuse care and recently she requested to be seen by podiatry. She stated the Social Worker was made aware a week ago and the resident was on the list to be seen by podiatry. She stated the nurses were responsible for trimming residents' toenails unless the resident was diabetic then a podiatry referral needed to be completed. She stated the potential risk of not trimming toenails was that it could lead to pain or bother the resident. During an interview on 04/23/26 at 2:38 p.m., the DON revealed the nurses were responsible for trimming the residents' nails unless the residents were diabetic. The DON stated she was not aware of how long Resident #83's toenails were. She stated during morning meeting it was mentioned that Resident #83 needed to be referred to podiatry and they were trying to put her on the podiatry list. The DON stated Resident #83 was known to refuse care but not aware if the resident refused toenails to be trimmed. She stated toenails needed to be trimmed for comfort. Record review of the facility's 24 Hour Report/Changes of Condition Report, dated 04/20/26, reflected [Resident #83] need podiatry consult/appointment. Record review of the facility's Foot and Toenail Care, Routine policy, reviewed 06/19/2023, reflected the following: Residents will be provided routine foot and toenail care within the professional scope of practice for CNAs, LVN/LPNs and RNs as is dictated per state guidelines and in accordance with standard practice.

Based on observation, interview and record review the facility failed ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of two residents (Resident #6) reviewed for catheter care. The facility failed to ensure Resident #6 had physician's orders for catheter care after he admitted to the facility with a suprapubic catheter. This failure could place residents at risk for infections and improper treatment. Findings include: Record review of Resident #6's admission MDS Assessment, dated 03/26/26, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. His MDS indicated he used an indwelling catheter. His diagnoses included Renal Insufficiency/Renal Failure/End-Stage Renal Disease (kidney failure) and diabetes mellitus (occurs when the body cannot properly use blood sugar). Record review of Resident #6's care plan, revised 04/09/26, reflected the following: Problems/Strengths: Urinary catheter- super pubic [sic].Interventions: Assess for bladder distention, small frequent voids, dribbling, resident complaint of bladder feeling full. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Watch for irritation around the catheter and help me to be sure it is in the right position so I will be comfortable. Care/changing of urinary catheter as ordered. Record review of Resident #6's April 2026 Treatment Record did not reflect any orders or care of his catheter. Record review of Resident #6's Physician Orders for April 2026 reflected there were not any orders for the care of his catheter. Record review of Resident #6's admission Data Assessment, dated 03/22/26, reflected he had a suprapubic catheter. Record review of Resident #6's interdisciplinary progress notes reflected the following:LVN A wrote on 03/22/26 at 12:00 p.m.: @ 12 p.m. Resident [AGE] years old male, arrived to facility via ambulance.Resident noted with s/p catheter in place draining clear urine catheter [sic] site dry and clean and intact. Observation and interview on 04/21/26 at 11:42 a.m. with Resident #6 revealed he was sitting in his wheelchair in his room. Resident #6 said he admitted a few weeks ago and before that he was at the hospital where he had a procedure completed to insert a suprapubic catheter. Resident #6 said he mostly completed his own catheter care but sometimes got assistance from staff as well. During an interview on 04/22/26 at 9:50 a.m., CNA D said she cared for Resident #6 and was familiar with the resident's care. CNA D said Resident #6 admitted to the facility with his catheter. CNA D said she helped him empty his catheter bag when it was too full and documented in his chart how much urine was in the bag. CNA D said sometimes he completed his own catheter care. During an interview on 04/22/26 at 9:55 a.m., LVN E said he cared for Resident #6 and was familiar with the resident's care. LVN E said Resident #6 admitted with his suprapubic catheter. LVN E said sometimes Resident #6 allowed staff to care for his catheter but most of the time he preferred to care for it himself. LVN E said he thought Resident #6 had catheter care orders in his chart, but when he looked in the electronic health record he did not find any. LVN E said the orders usually included emptying the catheter bag, changing the catheter when it was dislodged, flush it if it was not flowing, checking the tubing/line for kinks, and looking at the color of the urine. LVN E said all orders for care come from the doctor or nurse practitioner. During an interview on 04/23/26 at 9:43 a.m., the DON revealed Resident #6 admitted with his suprapubic catheter. The DON said Resident #6 should have orders for catheter care included in his chart. The DON said the nurse who admitted Resident #6 should have ensured he had catheter care orders entered into his chart. The DON said after a resident admitted , the ADON would go through the chart and ensure all orders were entered for the resident. The DON said the purpose of having catheter care orders was to make sure catheter care was being completed. The DON said Resident #6 mostly did his own catheter care, but when he needed assistance, staff would help him. The DON said if a resident did not have catheter care orders that could put them at risk of infection if staff were not caring for it. The DON said staff were trained to ensure residents had all care orders included in their chart upon admission. The DON said the orders for catheter care would include draining the catheter bag, checking the skin around the area, the sizing of the catheter, among other things. During an interview on 04/23/26 at 9:58 a.m., ADON F revealed Resident #6 admitted to her side of the building with a suprapubic catheter. ADON F said normally she would go behind the nurse after a resident was admitted to the facility to make sure all orders were entered into their chart regarding their care. ADON F said normally a resident who used a catheter would have orders that addressed monitoring the output, when to change the catheter, and would be put on enhanced barrier precautions. ADON F said Resident #6 was on her side of the building for only one night so that was why she did not go through his chart and make sure the catheter care orders were included after he was admitted . Record review of the facility's provided policy, revised 01/12/20, and titled Care and Removal of an Indwelling Catheter did not reflect the need for physician orders addressing catheter care.

Based on interview and record review the facility failed to ensure the attending physician documented in the resident's medical record that the identified drug irregularity had been reviewed and what, if any, action had been taken to address it and if there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 5 residents (Resident #2) reviewed for psychotropic medications. 1. The facility failed to ensure Resident #2's attending physician addressed the pharmacist's recommendation to consider a gradual dose reduction. Resident #2 had been receiving trazadone (an antidepressant) 100 MG every day since 07/31/25. 2. The facility failed to ensure Resident #2's attending physician addressed the pharmacist recommendation to review Resident #2's cyclobenzaprine (a muscle relaxer) Resident #2 had been receiving cyclobenzaprine 10 MG every day since 09/25/25. These deficient practices could place residents at risk of receiving a higher medication dose than necessary and result in adverse side effects.Findings include: Record review of Resident #2's Quarterly MDS Assessment, dated 03/03/26, reflected a female who admitted to the facility on [DATE]. Resident #2 had a BIMS score of 11, which indicated mild cognitive impairment. Resident #2's active diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent fear or worry that interferes with daily life and is difficult to control), paraplegia (a specific pattern of paralysis that affects the legs, resulting from a problem with the nervous system), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Resident #2 was noted to have taken antianxiety, antidepressant, and anticonvulsant medications. Resident #2 had not completed any GDR's for her medications. Record review of Resident #2's, undated, care plan reflected the following: Problems/Strengths: Medication: Potential for discomfort and side effects related to the use of Antidepressant. Resident takes.trazodone [sic]. Interventions: Physician to review medication.Monitor Duration- Prior to discontinuation may need a gradual dose reduction or tapering to avoid a withdrawal syndrome. Record review of Resident #2's progress notes for September 2025, October 2025, and January 2026 did not reflect any pharmacy recommendations were acted upon. Record review of Resident #2's April 2026 Physician Orders reflected the following:Trazodone Hydrochloride 100 MG, 1 tab by mouth at bedtime for Insomnia with a start date of 07/31/25.Cyclobenzaprine 10 MG, 1 tab by mouth three times a day for other muscle spasm with a start date of 09/25/25. Record review of Resident #2's April 2026 Medication Administration Record reflected she received her dose of trazodone as ordered each day as well as her doses of cyclobenzaprine each day as ordered. Record review of Resident #2's Recommendations for Doctor, dated 09/17/25, reflected the following: This patient [sic] is receiving Cyclobenzaprine is contiraindicatied [sic] in geriatric patientis [sic] due [NAME] [sic] it is [sic] stirong [sic] and anti-cholinergic effectis [sic] and risk off [sic] producing cognitive impairmenttiweakness [sic] and urine retiention [sic]. Please consider switching [NAME] [sic] a differenti [sic] antispasmodic such as tizanidine or bacloffen [sic] iff [sic] you ffeel [sic] iti [sic] is appropriatie [sic] tiherapy [sic]. There was not an additional document where the provider responded or reviewed the recommendation. Record review of Resident #2's Consultant Pharmacist's Medication Regimen Record review Recommendations Pending a Final Response, dated 10/21/25, reflected the following: This patient [sic] is receiving Cyclobenzaprine is contiraindicatied [sic] in geriatric patientis [sic] due [NAME] [sic] it is [sic] stirong [sic] and anti-cholinergic effectis [sic] and risk off [sic] producing cognitive impairmenttiweakness [sic] and urine retiention [sic]. Please consider switching [NAME] [sic] a differenti [sic] antispasmodic such as tizanidine or bacloffen [sic] iff [sic] you ffeel [sic] iti [sic] is appropriatie [sic] tiherapy [sic]. There was not an additional document where the provider responded or reviewed the recommendation. Record review of Resident #2's Recommendations for Doctor, dated 01/16/26, reflected the following: Resident is currently prescribed sedative/hypnotic TRAZODONE [sic] for the treatment of INSOMNIA [sic] since 7/25. According to CMS guidance under F605 (Chemical Restraints). 'For any resident who is receiving a psychotropic medication, the facility must show evidence that a gradual dose reduction has been attempted unless clinically contraindicated.' Please consider a trial dose reduction: If a GDR attempt is not indicated at this time, please indicate reasoning below. There was not an additional document where the provider responded or reviewed the recommendation. During an observation and interview on 04/21/26 at 10:30 a.m., revealed Resident #2 was in bed completing an activity. Resident #2 said she did not want anyone to change her medications because she liked what she was already receiving. Resident #2 said she had no concerns about the medications she received. During an interview on 04/23/26 at 11:10 a.m., ADON G said she was not sure how the pharmacy recommendations for Resident #2 were missed. ADON G said the pharmacist sent the emails with the recommendations to her and ADON F, then they printed them out and provided the recommendations to the providers (NP and Physician). ADON G said once the providers decided on the recommendations, they provided them back to her and ADON F. ADON G said then they changed or updated any orders based on what the response was for the pharmacy recommendation. ADON G said then the signed recommendation response was put back in the pharmacy recommendation binder or uploaded to the resident's chart. ADON G said she would have been responsible for ensuring Resident #2's pharmacy recommendations were completed and reviewed. ADON G said she did not have any proof and could not recall if Resident #2's pharmacy recommendations were reviewed back in September 2025, October 2025, or January 2026. ADON G said she would have the NP review them now and update the orders if needed. During an interview on 04/23/26 at 11:29 a.m., the NP and Physician, who were present on the phone only, said they received the pharmacy recommendations monthly and reviewed them at that time. The NP said once the recommendations were reviewed and an answer was provided on the forms, they were given back to ADON F and ADON G. The NP said she could not recall if Resident #2's pharmacy recommendations from September 2025, October 2025, and January 2026 were reviewed by her or not. The NP said she reviewed all the forms that were given to her, and she was at the facility 4-5 times per week. The NP said she reviewed the recommendations today for Resident #2 and did not make any changes because Resident #2 did not want her medications changed in any way. The NP said she could not say without looking at the situation further if there was any concern the pharmacy recommendations were not reviewed timely for Resident #2 and her medications. During an interview on 04/23/26 at 12:16 p.m., the DON said the ADONs were responsible for making sure the pharmacy recommendations were provided to the providers and followed up on. The DON said no one else ensured the pharmacy recommendations were followed up on by the providers or the ADONs. The DON said the ADONs were trained to ensure the pharmacy recommendations were followed up on and the recommendations were provided to the providers timely. The DON said she expected the ADONs to provide the recommendations to the providers and then update the orders if needed. The DON said if the pharmacy recommendations were not followed up on, any risk or concern to the resident would depend on the medication that was being reviewed. The DON said the purpose of following up on the pharmacy recommendations was to make sure the resident was on an appropriate medication, dose, and to consider reducing medications if needed. Record review of the facility's Medication Regimen Review and Reporting, policy, revised January 2024, reflected: .2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated.6. Resident-specific MRR recommendations and findings are documenta and acted upon by the nursing care center and/or physician.8. The nursing care center follows up on the recommendations to verify that appropriation action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols.

Based on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents (Resident #85) reviewed for intravenous fluids . 1. The facility failed to change and maintain the integrity of the dressing on Resident #85's midline catheter (an intravenous (IV) catheter inserted into a peripheral vein in the upper arm, with the tip positioned near the axilla, used for intermediate-term IV therapy) per professional standards.2. The facility failed to have physician orders to change Resident #85's midline catheter dressing, flushing, and to monitor for infection infiltration.These failures could place residents at risk for infections and cross-contamination.Findings include:Record review of Resident #85's admission MDS Assessment, dated 02/06/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included Non-Alzheimer's Dementia (problems with memory and thinking), hypertension (high blood pressure), acute respiratory failure with hypoxia (lungs cannot adequately transfer oxygen to the blood), chronic obstructive pulmonary disease (prevents airflow to the lungs), and heart failure. Resident #83's BIMS score was 07, which indicated severe cognitive impairment. The MDS did not address the use of antibiotics. Record review of Resident #85's care plan, dated 02/09/26, revealed Problems/Strengths: Resident incontinent of urine. Goals: Will be clean, dry and odor free daily. Interventions: Observe urinary frequency, color, odor, blood and report abnormalities to MD with follow up as indicatedRecord review of Resident #85's physician order, dated 04/08/26, revealed Invanz 1 GM Powder for solution (Ertapenem Sodium) for Urinary tract infection, site not specified for ESBL ([Start 04/08/26] 1 gram Injection One time daily [Time: 08:00AM] [Stop 04/18/26 12:00]) There was no order to change the PICC/Midline dressing using sterile technique every 7 days, and as needed, no orders for flushing and to monitor for infection and infiltration.During an observation and interview on 04/21/26 at 11:09 a.m., revealed Resident #85 was in his room, lying in bed. Resident #85 stated he was doing well. Resident #85 had a midline catheter in his upper left arm, and the dressing had a date of 04/12. Resident #85 stated he could not recall how long he had the midline. The resident denied any pain or discomfort. During an interview on 04/21/26 at 1:56 p.m., RN C revealed Resident #85 completed his antibiotic therapy. RN C reviewed Resident #85's physician orders and stated Resident #85 received antibiotics from 04/08/26 to 04/18/26. RN C stated Resident #85 did not have physician orders for midline dressing change, to flush the line or to monitor for infections. RN C entered Resident #85's room, observed Resident #85's midline dressing and stated the dressing was dated 04/12. She stated the dressing should be changed every 7 days but needed to obtain physician orders first. She stated she was not aware Resident #85 had no orders for his midline. RN C stated the nurses were responsible for obtaining physician orders, putting them in the system and the ADONs were responsible for following up to ensure the physician orders were correct. She stated the potential risk of not having physician orders was it could lead to infection. During an interview on 04/23/26 at 12:31 p.m., ADON F revealed the expectation was for nurses to obtain physician orders from the doctor that addressed midline dressing changes, flushing before and after medication, and monitor for any infection. She stated Resident #85 was receiving antibiotics and completed his treatment on Sunday (04/19/26). She stated the midline dressing should be changed every 7 days and once antibiotics were completed the assigned nurse should contact the doctor and obtain orders to remove the midline. ADON F stated if no physician orders to remove were obtained then nurses should still monitor the midline and change the dressing every 7 days. She stated it was the responsibility of the nurses to obtain physician orders and the ADONs to follow up to ensure orders were obtained. She stated the potential risk of not having physician orders would be bleeding or infection. During an interview on 04/23/26 at 2:36 p.m., the DON revealed midline dressing should be changed every Friday. She stated there should be orders for dressing change, flushing and monitoring. She stated she reviewed Resident #85's physician orders and she could not locate any physician orders pertaining to the midline. She stated it was the responsibility of the nurses to obtain orders and put them in the system. The DON stated it was the responsibility of the ADONs to ensure orders were obtained and for overseeing to ensure midline dressings were being changed. She stated the potential risk of not having physician orders would be treatment not getting done. During an interview on 04/23/26 at 4:27 p.m., the NP revealed she was aware Resident #85 was receiving antibiotics but was not aware the resident did not have physician orders. She stated the expectations were for physician orders to be obtained and be put in the system. She stated nurses should monitor the midline and dressing should be changed every 7 days or as needed. The NP stated there were several risks for not monitoring the site. Record review of the facility's Assessment of the Resident Receiving IV Therapy policy, dated October 2024, reflected the following: To enable the nurse administering infusion therapy to recognize and utilize appropriate interventions for infusion related problems or complications. Residents receiving infusion therapy will be monitored at established intervals based on prescribed therapy, and age, and conditions of resident and type of IV catheter. Check for integrity of the system and the dressing, correct infusate, accurate flow rate, and for expiration dates of the infusate, the dressing and the administration set.

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care provided to dependent residents. Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #1 received showers consistently for June and July 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident required extensive assistance with ADL care. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident was incontinent of urine and bowel. One of the approaches was for hygiene as needed after every incontinent episode to maintain dignity. Record review of Resident #1's Bath/Shower Sheets for the month of June and July 2025, reflected the resident received a shower on 06/14/25, 06/21/25, and 06/25/25. The resident was scheduled to received three showers a week on Monday. Wednesday and Friday. In an interview on 07/16/25 at 10:35 AM, Resident #1 stated she had only received bed baths since last year September 2024 and she and her RP [TF1] had been requesting for her to receive showers, with the most recent request being made during a Care plan meeting on 07/07/25. In a record review and interview on 07/16/25 at 10:40 AM, LVN S reviewed the shower sheets for July 2025 and none of them reflected the resident received a shower. She stated the resident was scheduled to receive her showers from the evening shift CNAs. She stated the CNA was not available at this time. She stated she thought the resident may have just requested bed baths but was not sure. She stated the nurses were responsible for checking to ensure residents received their showers. She stated if the resident was not receiving her scheduled showers on Monday, Wednesday, and Friday, they could have a skin breakdown. She stated various CNAs provided the resident her showers and was not really assigned to any specific person. She stated the CNAs were required to complete shower sheets whether the resident had received a shower, bed bath, or refused. In an interview on 07/16/25 at 10:49 AM, the RP for Resident #1 stated she attended the resident's care plan meeting on 07/07/25 and one of the concerns discussed was the resident not receiving showers since 2024 and the resident's desire to receive them as opposed to the bed baths. She stated the ADON K and DON stated they would ensure this would happen. She stated she was not aware of the resident ever refusing any showers and thought staff were avoiding using the Hoyer lift because they never had two people available to operate it. In an interview and record review on 07/16/25 at 11:15 AM, ADON K stated Resident #1 had been receiving showers and she had been requesting bed baths. She was advised the resident stated she had not received a shower since September 2024, and she stated she had been requesting a shower. She stated the shower sheets provided indicated the resident received showers and she followed up with staff to ensure they were providing showers to the residents when scheduled. She stated if the resident did not receive her showers, she could have skin problems. ADON K provided shower sheets which indicated the Resident received showers on 06/14/25, 06/21/25, and 06/25/25. She was advised this would be verified with Resident #1. In an interview on 07/16/25 at 11:50 AM, Resident #1 was asked if she received showers on 06/14/25, 06/21/25, and 06/26/25. She denied receiving any showers and repeated she had not received a shower since she arrived in September 2024 and only received bed baths. She stated she never refused a shower and would love to take showers. In an interview on 07/16/25 at 2:17 PM, the DON stated Resident #1 had an injury and initially wanted bed baths at the time, but this was some time ago. She stated the CNAs had gotten comfortable just giving her bed baths, had not asked her if she wanted a shower, and just assumed she wanted a bed bath. She stated she was told the resident refused showers, but it was never documented. She stated she was not aware the resident wanted showers until the care plan meeting. She stated the resident not getting a shower could be a dignity issue. Record review of the facility's policy, BATHING (NOT PARTIAL OR COMPLETED BED BATH) revised 01/23/23, revealed, Staff will provide bathing services for residents within standard practice guidelines. Residents have the right to choose if they want to be bathed at certain times and with certain methods in accordance to the care plan.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards.Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA D did not transfer Resident #1 using a Hoyer lift (a mechanical lift used to transfer an individual with limited mobility) by herself on 07/16/2025. This failure could place residents at risk of injury. Findings include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident required extensive assistance with ADL care. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident was incontinent of urine and bowel one of the approaches was for hygiene as needed after every incontinent episode to maintain dignity. In an observation and interview on 07/16/25 at 11:20 AM, Resident #1 was observed lying in bed and the Hoyer lift still positioned over her bed. There was only 1 CNA observed in the room. CNA D stated she and CNA S had assisted her in using the Hoyer lift to move the resident from her wheelchair to her bed. CNA D stated CNA S had just left the room. In an interview on 07/16/25 at 11:25 AM, Resident #1 stated it was only CNA D who was in the room using the Hoyer lift. She stated a lot of the time there was only 1 staff member using the Hoyer lift to get her out of and into her bed. In an interview on 07/16/25 at 12:20 PM, CNA she stated she did not assist CNA D with the transfer of Resident #1 from her wheelchair to the bed. She stated two people were required to operate the Hoyer lift to prevent the resident from falling. In an interview on 07/16/25 at 12:15 PM, ADON K was advised CNA D was observed in Resident #1's room with a Hoyer lift, the resident was apparently moved from her wheelchair to her bed, and she was the only staff member in the room. She was advised the resident stated CNA D was the only staff member who operated the Hoyer lift to move her into the bed. She stated they had just completed an in-service on Hoyer lifts, and the requirement was for two staff members to always use it. She stated the risk of not having two people, could result in the resident falling and getting injured. In an interview on 07/16/25 at 12:50 PM, CNA D was advised that CNA S was interviewed, and she denied assisting her with the Hoyer lift for Resident #1. CNA D stated she was trying to find someone else to assist her but could not. She stated they were supposed to use two people to operate the Hoyer lift for safety and to avoid the resident falling. In an interview on 07/16/25 at 2:17 PM, the DON stated two staff members were always required to use the Hoyer lift when lifting the resident. She stated it was for safety purposes. She stated they reviewed Hoyer lift procedures every year for the annual training and as needed but she could not recall the last time this was done. Record review of the facility's policy, Mechanical Lifts (Hoyer/Sit-To-Stand) reviewed 05/12/23, reflected Residents will be assisted with their Activities of Daily Living, utilizing lifts according to manufacturer's guidelines. Gather necessary equipment and second person to assist.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of 4 residents (Resident #1 and Resident #2) reviewed for respiratory care. Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of 4 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #1 and Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) and breathing mask (used to receive medications by breathing in mist through nose and mouth), were properly stored when not in use on 04/16/25. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment reflected the resident had Chronic Obstructive Pulmonary Disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident had a respiratory diagnosis and one of the approaches was to administer oxygen as ordered. Record review of Resident #1's Physician's Order, dated 07/16/25, reflected D/C @ 1 LPM via NC Every Shift. In an observation and interview on 07/16/25 at 10:35 AM, Resident #1 was observed with an Oxygen device in her room. The device was not in use and her nasal canula was observed hanging on the bedrail, unbagged. She stated she only used the oxygen device at night and had not used it since 6:30 AM. In an observation and interview on 07/16/25 at 10:40 AM, LVN [TF1] S stated she had been at the facility for 2 years. She stated Resident #1 used the oxygen device on an as needed basis. She stated they had to bag the resident's nasal canula when it was not in use. She was shown the nasal canula hanging from the resident's bedrail and she stated the bag was in the nightstand for storage and the nasal canula should have been stored in it for infection control. 2. Record review of Resident #2's face sheet, dated 07/16/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Chronic Obstructive Pulmonary Disease (lung disease). Record review of Resident #2's Comprehensive MDS Assessment, dated 01/30/25, reflected the resident was cognitively moderately impaired with a BIMS score of 11. The Comprehensive MDS Assessment reflected the resident had Chronic Obstructive Pulmonary Disease. Record review of Resident #2's Comprehensive Care Plan, dated 02/06/25, did not reflect an intervention for oxygen use. Record review of Resident #2's Physician's Order, dated 07/16/25, reflected D/C O2 at 2LPM by NC Every Shift [Time: Shift 2, Shift 1] Chronic obstructive pulmonarydisease, unspecified. In an observation on 07/16/25 at 11:20 AM, revealed Resident #2 was not in her room and her nasal canula was observed sitting on top of the resident's bed, unbagged. In an interview and observation on 07/16/25 at 11:25 AM, ADON K stated Resident #2 used an Oxygen device and when it was not in use, the nasal canula should be bagged to avoid an infection. She observed Resident #2's nasal canula sitting on top of the resident's bed, unbagged and the resident was not in the room. She stated the resident may have just left the room. She stated the nursing staff was responsible for checking to ensure oxygen masks and nasal cannulas were bagged when not in use. In an interview on 07/16/25 at 2:17 PM, the DON stated there was not a policy but it was common practice for staff to check to ensure the nasal cannulas were placed in a bag to avoid infection. Record review of the facility's policy, Oxygen Therapy - Discontinuation revised 01/12/20, reflecting The nursing licensed staff will discontinue oxygen therapy when ordered by physician, and according to practice guidelines. Remove cannula prong or mask from humidifier or regulator. (Discard if oxygen is not to be given again; or place in plastic bag if oxygen is to be administered on a PRN basis. Label and date.)

Based interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of 3 residents (Resident #1) reviewed for pharmaceutical services. Based interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one of 3 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Farxiga medication was in stock. This failure could place residents at risk of not receiving medication as ordered by the physician and having high glucose levels. Findings include: Record review of Resident #1's face sheet, dated 07/16/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had a diagnosis which included Diabetes. (condition that happens when blood sugar (glucose) is too high and develops when the pancreas doesn't make enough insulin or any at all, or when the body isn't responding to the effects of insulin properly.) Record review of Resident #1's Comprehensive MDS Assessment, dated 07/01/25, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had Diabetes. Record review of Resident #1's Comprehensive Care Plan, dated 07/16/25, reflected the resident had potential for hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes secondary to Diabetes and one of the approaches was to administer medications as ordered. Record review of Resident #1's Physician's Order, dated 07/16/25, reflected Farxiga 10 mg tablet, 1 tablet by mouth one time daily [Time: 08:00 AM]. In an interview on 07/16/25 at 10:30 AM, Resident #1 stated she was scheduled to take medication to treat her Diabetes daily but was advised this morning the medication was not available and needed to be reordered. In an interview on 07/16/25 at 10:40 AM, LVN S stated she had been at the facility for 2 years. She stated Resident #1 was prescribed Farxiga to take daily. She stated the resident was required to take the medication for her diabetes. She stated the resident was not able to take the medication this morning because the facility did not have it in stock. She stated the medication aide was responsible for re-ordering the medication and did not. She stated she was working on re-ordering the medication for the resident. She stated the risk if not getting medication could cause water in lungs. In an interview on 06/16/25 at 10:45 AM, LVN M stated he was filling in for the medication aide today because he was scheduled off. He stated Resident #1 was unable to receive her medication of Farxiga because it was not in stock. He stated the medication aide was responsible for re-ordering the medication and should have re-ordered it when there were 3 or 4 doses left. He stated he re-ordered the medication for the resident and was waiting for the prescription to be filled. He stated the risk of her not receiving the medication could result in a spike in her sugar level. In an interview on 07/16/25 at 2:17 PM, the DON was advised of Resident #1 not having her Farxiga medication and she stated she checked and found out the medication was only provided 14 days at a time. She stated she did not know why it was not ordered in advance. She stated most medication was 30, 60, 90 days in supply but her insurance only allowed 14 days at a time and it was ordered on the 7/01/25 but was somehow not received. She stated it was the medication aide's responsibility to re-order medication and to follow up to ensure the medication was ordered on 07/01/25. She stated she was unsure of the time period when they should re-order medication when it ran low. She stated the missed medication could impact the resident's sugar level Record review of the facility's policy, Medication Administration revised 01/2023 reflected Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Record review of the facility's policy, Medication Ordering And Receiving From Pharmacy Provider revised 01/12/2020 reflected Staff will order and receive medications from pharmacy providers in accordance with standard practice guidelines.

Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #1) of three residents reviewed for accuracy of records. The facility failed to add one of Resident #1's medication allergies, Sulfa, into the new operating system when they transferred the information. This failure could place residents at risk of not receiving medications as ordered which could cause a decline in the resident's overall health. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member. Resident #1 had 37 allergies listed which included: Albuterol, Methocarbamol, Levodopa, Acetaminophen, Oxycodone, Hydrocodone, Lidocaine, Docusate, Senna, Calcium Carbonate, Carbidopa, Ferrous Sulfate, Potassium Chloride, Iodine, Penicillin G, Polyethylene Glycol, Pantoprazole, Melatonin, Fluticasone, Cefazolin, Megestrol, Ketorolac, Ondansetron, Diphenhydramine, Tramadol, Zolpidem, Loratadine, Cefpodoxime, Fentanyl, Naproxen, Maltodextrin, Xanthan Gum, Furosemide, Prednisone, Morphine, Sulfa (Sulfonamide) and Propoxyphene. Resident #1 had diagnoses which included: Essential (primary) Hypertension (High Blood Pressure), UTI (an illness in any part of the urinary tract), and AMS (Altered Mental Status). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to Dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident #1's eMar for Bactrim revealed the medication was ordered on 3/13/25 and was administered at 8 p.m. The eMar showed the medication was discontinued on 3/14/25. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim DS not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes, dated 3/14/25 at 11:18 a.m. by RN-G, revealed Resident transferred to .hospital, per . [RR] request. NP notified. Record review of Notes dated 3/17/25 at 4:26 p.m., as late entry, from 3/14/25 11 a.m. by the DON, revealed Police officer arrived at facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with . [RR,] and stated that residents vitals were WNL, but . [RR] still wanted resident to go to the ER. Resident transferred to [hospital] and NP was notified. Per nurse, resident was still sleeping when [RR] arrived, but VS were assessed and stable. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. which stated it was Medication Related with no apparent injury, abuse or neglect ruled out and resident received medical treatment Record review of hospital Clinical Notes, dated 3/17/25, revealed Resident #1 had Delirium/encephalopathy, metabolic and toxic (change in mental status): In the context of someone who is very frail, severe malnutrition and probably pretty advanced dementia, very debilitated. Potential causes and contributors: It is possible this is a side effect of medication. Also possible for UTI but no fevers and no leukocytosis .Avoid sulfa drugs, doubt if patient's current symptoms are related to Bactrim .The patient had to get fluid bolus (a single, large dose) in the ER .The patient also started on ceftriaxone for UTI, but [RR] refused antibiotics. Record review of hospital discharge summary, dated 3/18/25 at 9:31 a.m., revealed Resident #1 had sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus .she was admitted to ICU for pressor support (use of medications called vasopressors to increase blood pressure and improve blood flow) but did not require that .there was no skin rash noted. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated the facility changed over their on-line documentation system manually and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The Admin stated they did not know the medication was missed until Resident #1's RR stated she had an allergy to Sulfa drugs. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m., LVN-C stated if a resident was prescribed a new medication order by the doctor, the resident's allergy list was in the system. LVN-C stated she would call the pharmacy to verify there were no drug allergies if she was in question. Interview on 3/19/25 at 1:08 p.m., CMA-D stated a resident's allergy list was checked by the doctor and the nurse before a medication was ordered. He stated the nurses gave medication to Resident #1 as the RR requested. Attempted interview on 3/19/25 at 3:33 p.m. with RN-E, left message and sent text. Attempted interview on 3/19/25 at 3:48 p.m. with RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m. with NP, stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 4:37 p.m., the Admin stated it was a simple human error that the Sulfa drug allergy was not switched over to the new medical documentation system. Interview on 3/19/25 at 8:22 p.m., RN-F stated a medication technician or nurse would give a resident their medications unless a family member wanted a nurse to administer medications. She stated if a resident had an allergy, when a new prescription was put in the system, the system would have a pop-up showing there was an allergy listed. Interview on 3/19/25 at 8:29 p.m., RN-E stated last Thursday, 3/13/25, Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on Resident #1's allergy list. RN-E stated the NP prescribed Bactrim with the 1st dose started that night.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of three residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to update Resident #1's allergy list completely when they manually transcribed the information into their new operating system. 2) The facility failed to ensure Resident #1 was not administered Bactrim (Sulfa drug) on 3/13/25 when Resident #1 had an allergy to Sulfa. These failures could place residents at risk of receiving medications they have allergies to which could contribute to adverse reactions resulting in a decline in health and/or hospitalization . Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member. Resident #1 had 37 allergies listed which included: Albuterol, Methocarbamol, Levodopa, Acetaminophen, Oxycodone, Hydrocodone, Lidocaine, Docusate, Senna, Calcium Carbonate, Carbidopa, Ferrous Sulfate, Potassium Chloride, Iodine, Penicillin G, Polyethylene Glycol, Pantoprazole, Melatonin, Fluticasone, Cefazolin, Megestrol, Ketorolac, Ondansetron, Diphenhydramine, Tramadol, Zolpidem, Loratadine, Cefpodoxime, Fentanyl, Naproxen, Maltodextrin, Xanthan Gum, Furosemide, Prednisone, Morphine, Sulfa (Sulfonamide) and Propoxyphene. Resident #1 had diagnoses which included: Essential (primary) Hypertension (High Blood Pressure), UTI (an illness in any part of the urinary tract), and AMS (Altered Mental Status). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to Dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident #1's Notes, dated 3/14/25 at 1:29 a.m. by RN-F, revealed there was a new order per NP, Bactrim DS 1 Tab .6 doses, start today. Asked NP if she was going to call and notify residents /RR, she denied. Orders noted, transcribed and initial does [sic] given. Record review on Resident #1's notes dated 3/14/25 at 1:54 a.m. by RN-F, revealed at approximately 9:30 p.m., Resident #1's RR approached nursing with clear agitation and aggression asking what medication her [Resident #1] was given and why. Explained to her the NP ordered Bactrim 1 Tab .6 doses and this nurse administered the first dose, no adverse reactions noted by this nurse RR stated, she should have been consulted for consent and because of the antibiotic [ Resident #1's] hands are shaking. Record review of Resident #1's eMar for Bactrim revealed the medication was ordered on 3/13/25 and was administered at 8 p.m. The eMar showed the medication was discontinued on 3/14/25. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim DS not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes, dated 3/14/25 at 11:18 a.m. by RN-G, revealed Resident transferred to .hospital, per . [RR] request. NP notified. Record review of Notes dated 3/17/25 at 4:26 p.m., as late entry, from 3/14/25 11 a.m. by the DON, revealed Police officer arrived at facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with . [RR,] and stated that residents vitals were WNL, but . [RR] still wanted resident to go to the ER. Resident transferred to[hospital]and NP was notified. Per nurse, resident was still sleeping when [RR] arrived, but VS were assessed and stable. Record review of Notes, dated 3/18/25 at 7:47 p.m. by RN-E, revealed Resident arrived Facility at 1705 [5:05 p.m.] from [hospital] with DX: UTI, report received from nurse .that Resident received no treatment for UTI as her [RR] refused meds that were prescribed for UTI. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. which stated it was Medication Related with no apparent injury, abuse or neglect ruled out and resident received medical treatment Record review of hospital Clinical Notes, dated 3/17/25, revealed Resident #1 had Delirium/encephalopathy, metabolic and toxic (change in mental status): In the context of someone who is very frail, severe malnutrition and probably pretty advanced dementia, very debilitated. Potential causes and contributors: It is possible this is a side effect of medication. Also possible for UTI but no fevers and no leukocytosis .Avoid sulfa drugs, doubt if patient's current symptoms are related to Bactrim .The patient had to get fluid bolus in the ER .The patient also started on ceftriaxone for UTI, but [RR] refused antibiotics. Record review of hospital discharge summary, dated 3/18/25 at 9:31 a.m., revealed Resident #1 had sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus .she was admitted to ICU for pressor support but did not require that .there was no skin rash noted. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated Resident #1 had a UTI, and she was started on Bactrim. She was given one dose and the RR wanted them to call to get permission before giving any medications. The Admin stated if Resident #1 could answer, they did not need to get permission from RR. The Admin stated on 3/14/25, Resident #1's RR felt Resident #1 needed medical care at the hospital. Resident #1 was sent to the hospital, and they gave Resident #1 a liter of fluids and that was about it. The Admin stated RR did not believe the resident had a UTI and refused the hospital from giving any antibiotics. The Admin stated the facility changed over their on-line documentation system manually and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The Admin stated they did not know the medication was missed until Resident #1's RR stated there was an adverse reaction to the Bactrim. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. The DON stated Resident #1 was lucid at times. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m., LVN-C stated if a resident was prescribed a new medication order by the doctor, the resident's allergy list was in the system. LVN-C stated she would call the pharmacy to verify there were no drug allergies if she was in question. Interview on 3/19/25 at 1:08 p.m., CMA-D stated a resident's allergy list was checked by the doctor and the nurse before a medication was ordered. He stated the nurses gave medication to Resident #1 as the RR requested. Attempted interview on 3/19/25 at 3:33 p.m. with RN-E, left message and sent text. Attempted interview on 3/19/25 at 3:48 p.m. with RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m. with NP, stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 4:37 p.m., the Admin stated it was a simple human error that the Sulfa drug allergy was not switched over to the new medical documentation system. Interview on 3/19/25 at 8:22 p.m., RN-F stated a medication technician or nurse would give a resident their medications unless a family member wanted a nurse to administer medications. She stated if a resident had an allergy, when a new prescription was put in the system, the system would have a pop-up showing there was an allergy listed. RN-F stated there was concern Resident #1's RR was not allowing staff to provide care. She stated the RR had so many drug allergies listed, it was difficult to find an antibiotic that could be given to Resident #1. RN-F stated the RR told her the medications made Resident #1's eyes red. Interview on 3/19/25 at 8:29 p.m., RN-E stated last Thursday, 3/13/25, Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on Resident #1's allergy list. RN-E stated the NP prescribed Bactrim with the 1st dose started that night. RN-E asked the NP if she was going to call the RR, but she said no because the RR hinders the resident's care. RN-E stated she obtained the Bactrim medication out of their emergency kit. RN-E stated the RR called the police after she arrived and found out the medication was given without her consent. She stated the police officer wound up escorting RR out of the building to deescalate the situation that night. RN-E stated she was not working when Resident #1 was sent out to the hospital the next morning. She stated she did not see Resident #1's hands shake at all night before. Attempted interview on 3/20/25 at 11:52 a.m. with the police department/PD, stated Officer-H and Officer-I worked the scene when Resident #1 was sent out to the hospital, but Officer-H was on vacation this week and Officer-I did not work until 7 p.m. tonight. Interview on 3/20/25 at 8:37 p.m. with Officer-I, stated he was present the evening of 3/13/25, but was not there on 3/14/25 when Resident #1 was sent to the hospital. Officer-I stated RR was complaining about several different things regarding the treatment of Resident #1, including staff not consulting her prior to giving medications.

Based on interview and record review the facility failed to ensure the resident representative had the right to exercise the resident's rights to the extent those rights are delegated to the representative for one of three residents (Resident #1) reviewed for resident rights. The facility failed to obtain consent from Resident #1's RR, prior to administering an antibiotic medication which resident was allergic to. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Include: Record review of Resident #1's face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1's face sheet identified her representative was a family member, RR. Resident #1's RR was listed as medical power of attorney. Resident #1 had diagnoses which included: Essential (primary) Hypertension (high blood pressure), Urinary Tract Infection (UTI), and AMS (Altered Mental Status). Resident #1's face sheet had 37 allergies listed including Sulfa. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 10, which meant moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 1/25/25, revealed the resident had Cognitive loss due to dementia. Resident #1 had potential for discomfort and side effects related to medication allergies. Resident #1 becomes easily agitated and anxious at times. Record review of Resident Admission Agreement for Resident #1, entered into as of 08/15/2022, showed Resident #1 had RR listed as her Resident Representative. Record review Resident #1's Statutory Durable Power of Attorney dated 10/18/16, revealed the RR was Resident #1's power of attorney and stated, power of attorney is not affected by my subsequent disability or incapacity. Record review of Resident #1's Medical Power of Attorney, dated 1/11/18, revealed the RR was Resident #1's medical power of attorney. Record review of Resident #1's Notes, dated 3/14/25 at 1:29 a.m. by RN-E, revealed there was a new order per NP, Bactrim 1 [Tablet] .6 doses, start today. Asked NP if she was going to call and notify residents RR, she denied. Orders noted, transcribed and initial does [sic] given. Record review on Resident #1's notes dated 3/14/25 at 1:54 a.m. by RN-E, revealed at approximately 9:30 p.m., Resident #1's RR approached nursing with clear agitation and aggression asking what medication [Resident #1] was given and why. Explained to her that the NP ordered Bactrim 1 [Tablet] .6 doses and this nurse administered the first does, no adverse reactions noted by this nurse . [RR stated], she should have been consulted for consent. Record review of Notes dated 3/14/25 at 10:59 a.m. by RN-G revealed Morning antibiotic medication Bactrim not administered. Resident allergic to surfa [sic]. Call placed to NP new order received to stop medication. Medication discontinued as ordered by physician. Record review of Notes dated 3/14/25 at 11:18 a.m. by RN-G revealed Resident transferred to . hospital, per daughter request. NP notified. Record review of Notes on 3/17/25 at 4:26 p.m., as late entry from 3/14/25 at 11:00 a.m. by the DON revealed the Police officer arrived at the facility, unsure of who called for an officer. Discovered that .[RR], called the police to discuss events from previous night. Officer went in and spoke with .[RR], and stated that resident's vitals were WNL, but .[RR] still wanted resident to go to the ER. Resident transferred to .[hospital] and NP was notified. Per nurse, resident was still sleeping when .[RR] arrived but VS were assessed and stable. Record review of Notes on 3/18/25 at 7:47 p.m. by RN-F revealed Resident arrived Facility at 1705 from .[hospital] with DX: UTI, report received from nurse .that Resident received no treatment for UTI as her .[RR] refused meds that were prescribed for UTI. Record review of the facility's Incident Log Report revealed there was an incident regarding Resident #1 on 3/14/25 at 9:01 a.m. stating it was Medication Related with no apparent injury, abuse or neglect was ruled out and resident received medical treatment. Record review of the hospital discharge summary, dated 3/18/25 at 9:31 a.m., revealed Resident #1 was discharged with diagnoses which included Acute encephalopathy (sudden and significant decline in brain function) due to transient hypovolemia (temporary reduction in blood volume), Hypotension (low blood pressure), Asymptomatic bacteriuria (presence of bacteria in urine), COPD (Chronic obstructive pulmonary disease; a group of lung diseases that cause airflow obstruction and breathing problems), Chronic memory impairment (persistent decline in ability to remember information over time) and MTHFR gene mutation. Under Hospital course: Patient is an [AGE] years [sic] old woman with history of atrial fibrillation (irregular heartbeat) COPD, hypertension, MTHFR gene mutation (change in DNA sequence can disrupt enzyme's normal function) and hand [sic} sulfa allergy who had abnormal urinalysis and was given Bactrim at the skilled nursing facility. Per RR, patient become [sic] confused afterwards and was brought to hospital. She was hypotensive requiring IV fluid bolus. She was admitted to ICU for pressor support but did not require that. Patient become [sic] alert afterwards remained without fever, dysuria (discomfort when urinating), frequency, or urgency. No leukocytosis (increased number of white blood cells). No antibiotics were administered in the hospital .There was no skin rash noted .She is medically ready to go back to her long-term residential facility. Sulfa drugs should be avoided in the future. Interview on 3/19/25 at 8:48 a.m. with Resident #1's RR revealed she was the medical and financial power of attorney. RR stated Resident #1 was unable to give consent because she had a learning disability. RR stated she went in the facility on 3/13/25 around 8:30 p.m. She stated the facility had given Resident #1 an antibiotic, Bactrim without getting her consent. RR stated the facility is supposed to get her consent prior to any medication changes or new medications. RR believed Resident #1 suffered neurotoxic side effects from the Bactrim as Resident #1 had a tremor in her right hand, she looked sedated, and the whites of her eyes were bloodshot. RR stated when she arrived the morning of 3/14/25, Resident #1 was unresponsive. Interview on 3/19/25 at 10:58 a.m. with the Admin and the DON. The Admin stated Resident #1 had a UTI, and she was started on Bactrim. She was given one dose and the RR wanted them to call to get permission before giving any medications. The Admin stated if Resident #1 could answer, they did not need to get permission from RR. The Admin stated on 3/14/25, Resident #1's RR felt Resident #1 needed medical care at the hospital. Resident #1 was sent to the hospital, and they gave Resident #1 a liter of fluids and that was about it. The Admin stated RR did not believe the resident had a UTI and refused the hospital from giving any antibiotics. The Admin stated the facility changed over their on-line documentation system and the sulfa drug allergy for Resident #1 was missed during the transition. He stated it was in the system now. The DON stated she went through all the residents' medications and there were no other errors besides Resident #1's. The DON stated Resident #1 was lucid at times. Interview on 3/19/25 at 11:42 a.m., Resident #1 stated she could not remember why she went to the hospital but said that was why she was in the facility. She stated staff treated her terrible, but she was not going to get into that and told the state surveyor to talk to her RR. Resident #1 did not recall if she had ever gotten the wrong medication. Interview on 3/19/25 at 12:41 p.m. with LVN-C, stated if she received a new medication order, the medication allergy list was in the system. LVN-C stated the doctor would have access to the allergy list in the system. LVN-C stated she would call the pharmacy to verify there was no allergy for the resident. LVN-C stated by the time the medication was ready to be administered, the medication would have been checked by the doctor and the nurse for allergies. LVN-C stated if a resident had a UTI, they may have had confusion, altered mental status, been off baseline, a change in condition or had a burning sensation. She stated if the resident was suspected of having a UTI, she would contact the doctor for further orders. LVN-C was familiar with Resident #1 since her admission. She stated there was nothing done without her RR being aware. LVN-C stated she would check with the RR to see if she consented to any medication prior to giving it. Interview on 3/19/25 at 1:08 p.m., CMA-D stated the medication allergy list was checked by the doctor and the nurse before it was administered. He stated he did not give medication to Resident #1 because the nurses did. CMA-D stated some family members wanted the nurses to give residents their medications. Attempted telephone call on 3/19/25 at 3:33 p.m. to RN-E, left message and sent text. Attempted telephone call on 3/19/25 at 3:48 p.m. to RN-F, left message and sent text. Interview on 3/19/25 at 3:52 p.m., NP stated regarding Resident #1, the Sulfa allergy was not on her list when she made the orders for Bactrim. The NP stated she did not know Resident #1 had the allergy to Sulfa drugs until the pharmacy let her know. The NP stated if she had known there was a Sulfa allergy, she would not have ordered Bactrim. Interview on 3/19/25 at 8:22 p.m., RN-F stated if a resident had a drug allergy, when a new prescription was put in the computer system, it would pop up showing there was an allergy. She stated both the NP, and she would have called the RR for consent to give a medication. RN-F stated she would call the RR herself to make sure she had knowledge of any medications because there were issues in the past. Interview on 3/19/25 at 8:29 p.m., RN-E stated on 3/13/25 Resident #1's UTI cultures came back positive. She stated Sulfa drugs were not listed on her allergy list in the computer system. The NP prescribed Bactrim, 6 doses with the 1st dose started that night. She stated the order started that night, so she got it out of the facility's emergency kit. RN-E stated when the NP made the order, she asked if she was going to call the RR. The NP stated she would not because the RR hinders Resident #1's care. RN-E stated she was in the room with the NP when she explained to Resident #1 what she was going to give her, the resident agreed, and she exited the room. RN-E stated when she got the medication, she explained to Resident #1 what the medication was for prior to giving it to her and Resident #1 said okay. RN-E stated the RR came in later and asked what had been given to Resident #1. She let her know the NP had given orders for Bactrim. RN-E stated RR started raising her voice and yelling she had not given consent for the medication. RN-E stated the RR called the police to the facility which she had done 3 or 4 times in a row because she did not feel they were doing their job correctly. The police wound up escorting the RR out of the facility for the night and allowed things to calm down. RN-E stated she did not see Resident #1's hands shake at all that night. RN-E stated she was not working the next morning when Resident #1 was sent to the hospital. RN-E stated the hospital discharge notes stated the RR refused to give any antibiotics while Resident #1 was there. RN-E stated the RR was worried about altered mental status from the Bactrim, but it could have been from the UTI. RN-E stated the NP had always called for approval from the RR in the past. She stated the NP, or the DON would call for consent from the RR. Record review of the facility's Resident Rights, dated 8/14/20, stated under Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines .Procedure: Staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Record review of the facility's Resident Admission Agreement, dated 9/24/21, revealed under Resident Representative is defined in the federal regulations governing nursing facilities as any of the following: a. an individual chosen by the resident or a person authorized by State of Federal law .to act on behalf of the resident in order to (i) support the resident in decision-making; (ii) access medical, social or other personal information of the resident .

Based observation, interview, and record review, the facility failed to ensure proper handling of the ice to prevent contamination and the potential for waterborne illness by one CNA (CNA D) out of four staff attending to the residents during lunch time. The facility failed to ensure CNA D did not put the ice scooper on the bowl of ice while preparing drinks for the residents during lunch time on 01/22/2025. This failure could place the residents at risk of cross-contamination and development of infections. Findings included: An observation on 01/22/2025 at 12:03 PM revealed CNA D was preparing some drinks for the residents. At the middle of the dining area was a table with some boxes of milk, a bowl of ice, a small plate, and some pitchers of iced tea. She placed four glasses on a tray, scooped some ice from a bowl of ice, and put them on the glasses. She used an ice scooper to put the ice. After she put the ice on the glasses, she placed the scooper on the bowl of ice, and poured iced tea on the glasses. She put the scooper on top of the bowl of ice with the handle of the scooper touching the ice. She used her bare hands when she used the scooper. She gave the glasses to the residents. she went back to the table, placed five glasses on the tray, took the scooper on top of the ice, scooped some ice, put it on the glasses, returned the scooper on top of the ice, poured some iced tea on the glasses, and gave them to the residents. She returned to the table, placed four glasses on the tray, took the scooper on top of the ice, scooped some ice, put it on the glasses, returned the scooper on top of the ice, poured some iced tea on the glasses, and gave them to the residents. a small plate was noted beside the bowl of ice. In an observation and interview with ADON A on 01/22/2025 at 12:12 PM, ADON A stated the scooper should be placed on the plate beside the ice bowl and not on top of the ice that were inside the bowl of ice. She said putting the handle on the bowl of ice could contaminate the ice. She said germs could transfer from hands to ice scooper handle to ice. ADON A took the bowl of ice and replaced it. she also took the glasses of iced tea given to the residents and replaced them. She said she would talk to CNA D and would remind her to put the scooper on the small plate beside the bowl of ice. In an interview with CNA D on 01/22/2025 at 12:30 PM, CNA D stated the handle of the scooper that she held should not touch the ice to prevent transfer of germs. She said she also touched the tray she used to give the residents their drinks and she was not sure if the tray was clean. She said she should have put the ice scooper on the small plate beside the bowl of ice. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the ice scooper should be placed on the small plate beside the bowl of ice. She said placing the handle of the ice scooper inside the ice could contaminate the ice that were put in glasses for the residents. She said her expectation was for the staff to be mindful with the manner they served the residents. She said she would do an in-service about infection control and would include proper handling of the ice scooper because putting it on top of the ice could contribute to cross contamination and infection. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the ice scooper should be placed on the small plate beside the bowl of ice and not on top of the ice to prevent contaminating the ice that would be used for the residents' drinks. He said the expectation was for the staff to be mindful when they were preparing the drinks of the residents. He said he would collaborate with the DON about the infection control issue. Review of facility policy, Ice Storage . Sanitary Care . and DEPARTMENT: Infection Control Policy and Procedure revised August 2018 revealed Policy: Sanitary care . Procedures . B. Hold ice scoops by the handle; do not touch ice . C. Only ice scoops are used to obtain ice . F. Limit access to the handling of ice and ice-storage devices to minimize contamination . Ice Scoops: 1. Scoops are kept in a covered stainless steel, impervious plastic, or fiberglass tray when not in use.

Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy and confidentiality which includes privacy during medical treatment and confidentiality of medical records for four (Resident #31, Resident #42, Resident #79, and Resident #91) of eighteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure RN E and RN F closed the door while administering Resident #79's breathing treatment on 01/23/2025. 2. The facility failed to ensure RN E closed the door while administering Resident #91's medication through g-tube on 01/23/2025. 3. The facility failed to ensure MA I did not leave Resident #31's and Resident #42's health information on top of the medication cart unattended on 01/23/25. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Review of Resident #79's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #79's was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #79's Quarterly MDS Assessment, dated 12/11/2024, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Review of Resident #79's Care Plan, dated 12/31/2024, reflected the resident used a respiratory medication and one of the interventions was to administer medications as ordered. Review of Resident #79's Physician Order, dated 11/18/2024, reflected ALBUTEROL SULFATE 0.083% SOLUTION (Albuterol Sulfate) 3 ml Inhalation nebulization Three times a day [Time: 08:00 AM, 12:00 PM, 08:00 PM] for Chronic obstructive pulmonary disease, unspecified. Observation and interview with RN E on 01/23/2025 at 8:18 AM revealed RN E and RN F were about to administer breathing treatment to Resident #79. RN E and RN F sanitized their hands, put on their gowns and gloves, and went inside the resident's room. RN E took the resident's breathing mask from the plastic bag, poured the breathing treatment solution to the nebulizer cap, and put it on the resident's face covering the mouth and the nose. RN E went to the bathroom and washed her hands. After washing her hands, RN E went out of the resident's room. RN E said RN F would wait for the breathing treatment to be done. From the hallway, it could be seen that the resident was having his breathing treatment. It could also be seen that RN F was sitting in a chair across the room. In an interview with RN E on 01/23/2025 at 8:50 AM, RN E stated doors should be closed when providing care to the residents to provide them privacy and dignity. She said she thought she closed the door after washing her hands. She said she should have doubled check if the door was close or have told RN F to close the door. She said it did not matter if the resident would mind or not, the door should be closed. She said Resident #79 was non-verbal and would not be able to tell her if he wanted the door closed or not and if he was embarrassed or not. 2. Review of Resident #91's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE]. Resident #91's was diagnosed with gastrostomy status. Review of Resident #91's Quarterly MDS Assessment, dated 11/25/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 01. The Quarterly MDS Assessment indicated the resident was on feeding tube (delivery of food through a tube to the stomach) while a resident of the facility. Review of Resident #91's Care Plan, dated 11/26/2024, reflected the resident used anticonvulsant and one of the interventions was to administer medication as ordered. Review of Resident #91's Physician Order, dated 01/09/2025, reflected GABAPENTIN 300 MG CAPSULE (Gabapentin) 1 capsule Gastrostomy Tube (a tube that is surgically inserted through the skin of the belly and into the stomach) Three times a day [Time: 08:00 AM, 12:00 PM, 08:00 PM]. Observation and interview with RN E on 01/23/2025 at 12:03 PM revealed RN E was about to administer Resident #91's medication through g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). She went inside the room and told the resident that she would be giving her the 12:00 PM medication. RN E went to the bathroom to wash her hands. She said the resident would only have one medication for 12 PM. She then put one capsule of gabapentin to a small plastic cup and then opened it and placed the content of the capsule into the small plastic cup. She then put some water on a plastic cup. She said she would use the water to dissolve the gabapentin and to flush the g-tube before and after the medication administration. After preparing the water, she sanitized the bell of her stethoscope and let it dry. She went inside the room and took with her the medication, the cup of water, and some small cups. She placed the things that she would be using on the resident's overbed table, took the resident's syringe from the resident's bedside, and placed it also on the overbed table. RN E positioned herself and the overbed table on the resident's left side. RN E was facing the door. She did not close the door and the privacy curtain was not pulled all the way through. From the hallway, it could be observed that RN E pulled the resident's gown up to expose the feeding port, checked for placement and residual, dissolved the medication, flushed the g-tube, administer the medication, and flushed again after the medication was give. RN E said she forgot to close the door again or at least pulled the privacy curtain all the way through while administering the resident's medication. She said the door should be closed or the privacy curtain pulled all the way through to provide privacy and give dignity to the resident. She said she would make sure she would close the door every time she was providing care. In an interview with ADON A on 01/23/2025 at 1:39 PM, ADON A stated all care should be done in the privacy of the residents' room to promote dignity. She said every care done by the staff should be behind the door so other staff, other residents, or even the visitors would not see or speculate the medical condition of the residents. She said it did not matter if the residents care or not, the door should still be closed while providing care. She said it was important that the residents would be safe and would not be embarrassed. She said the expectation was for the staff be mindful when they were providing care. She said she would coordinate with the DON to do an in-service closing the door while providing care to enable a dignified existence because the facility was their home. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the door should be closed when administering the breathing treatment and medication. She said the privacy curtain should be pulled all the way so that even though the door was open, nobody could see the care being provided. She said the door should be closed to provide dignity to the residents and to avoid embarrassment. The DON said all the staff, including her, were responsible in providing dignity to the residents. The DON said the expectation was for the staff to make sure that when they were providing care, the residents' door was closed, or the privacy curtain were pulled all the way. She concluded that she would continually remind the staff the importance of providing privacy and dignity through an in-service. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment. She said the expectation was for the staff to close the door, not only during medication administration, but during all care provided. He said he would collaborate with the DON and the ADON to do an in-service about closing the door to provide dignity. In an interview with RN F on 01/24/2025 at 2:39 PM, RN F stated the door should be closed every time a staff was providing care to the residents. RN F said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. RN F said she should have closed the door when RN E left Resident #79's room. 3. Review of Resident #31's face sheet, dated 01/23/2025, reflected a [AGE] year-old female resident admitted to the facility on [DATE] with Non-Alzheimer's Dementia. Review of Resident #31's Quarterly MDS Assessment, dated 12/20/2024, reflected severely impaired cognition with a BIMS score of 1. Section I reflected an active diagnosis was Non-Alzheimer's Dementia. Review of Resident #31's Care Plan, dated 12/24/2024, reflected the resident had cognitive deficit related to dementia. One intervention was allow ample time for task completion. Review of Resident #42's face sheet, dated 01/23/2025, reflected an [AGE] year-old female resident admitted to the facility on [DATE] with Non-Alzheimer's Dementia. Review of Resident #42's Quarterly MDS Assessment, dated 12/31/2024, reflected a BIMS test was not conducted for the resident. Section I reflected an active diagnosis was Non-Alzheimer's Dementia. Review of Resident #42's Care Plan, dated 12/10/2024, reflected the resident had cognitive deficit related to dementia. One intervention was encourage simple leisure activities. An observation and interview on 01/23/25 at 03:19 PM revealed a document on top of the medication cart with residents' personal health information on it. The medication cart was parked at the beginning of the 400 hall and next to a resident sitting area. No staff member was near the medication cart. There were 3 labels affixed to the blank sheet of paper on top of the medication cart. Each label reflected a resident's name, room number, and the name of a medication. Two of the labels reflected a medication refill for Resident #31 and the other label reflected a medication refill for Resident #42. During the observation, MA I approached the cart and was asked about the resident information on top of the medication cart. MA I stated she was going to fax the document to the pharmacy to request medication refills for the residents. She stated she accidentally left it out. She stated it was confidential information and that no one needed to see it. MA I immediately removed the document. During an interview on 01/24/25 at 09:27 AM, ADON B stated it was a HIPAA violation to leave residents' health information out for everyone to see. She stated it was a violation of the residents' rights to have their personal information accessible to others. She stated the facility will provide in-service training to remind staff of this. During an interview on 01/24/25 at 10:22 AM, the Administrator stated when MA I was not at the medication cart, his expectation was for any resident information to be covered up. He stated MA I should have turned the paper over or removed it so resident health information was not seen. The Administrator stated he had the same expectation for a paper document with resident information as he did for a computer screen with resident information visible. He stated he would expect a computer screen to be closed if staff was not using it. In an interview on 01/24/25 at 03:38 PM, the DON stated it was a HIPAA violation to leave residents' personal information out where someone could walk by and see it. The DON stated her expectation was for all staff members to protect residents' personal health information. Record review of facility's policy, Resident Rights Policy and Procedure revised August 14, 2022, revealed Policy: The staff will abide by and protect resident rights in accordance with state and federal guidelines . the resident has the right for a dignified existence.

Based on observation, interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for two (Resident #20 and Resident #49) of eight residents reviewed for Accuracy of Assessments. 1. The facility failed to ensure Resident #20's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter (non-invasive device used to manage urinary incontinence) and was on oxygen therapy. 2. The facility failed to ensure Resident #49's Quarterly MDS assessment dated [DATE] accurately reflected that the resident was receiving Hospice Care (end of life care). This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: 1. Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder (sudden urges to urinate) and respiratory failure. Review of Resident #20's Quarterly MDS Assessment, dated 12/24/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. Resident #20's Quarterly MDS Assessment did not indicate that the resident was using an external catheter and was on oxygen administration. Review of Resident #20's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with elimination and one of the interventions was to assist with PureWick (non-invasive urinary drainage device that uses suction to collect urine from the body) as per orders and resident request. The Comprehensive Care Plan also indicated the resident was on oxygen therapy and one of the interventions was administer oxygen as ordered. Review of Resident #20's Physician Order, dated 01/22/2025, reflected purewick drain On Night Shift. Review of Resident #20's Physician Order, dated 11/01/2024, reflected O2 at 2 LPM by NC at Bedtime [Time: 08:00 PM] for Acute respiratory failure with hypercapnia (increased amount of carbon dioxide to the body). Observation and interview with Resident #20 on 01/22/2025 at 10:15 AM revealed Resident #20 was in her bed, awake. It was observed that a purewick system was at the resident's bedside. The resident said she used it every night and she had been using it since last year. It was also observed that the resident was on oxygen therapy via nasal cannula. In an interview with LVN B on 01/22/2025 at 10:47 AM, she said the Purewick system was an external catheter used by Resident #20 every night. She said the family was the one who requested that the resident use it. She said the resident had the purewick since she was admitted to the facility last year. She also said the resident was on oxygen for respiratory failure. 2. Record review of Resident #49's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 was diagnosed with CVA (cerebrovascular disease: blood supply to the brain was interrupted). Record review of Resident #49's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment did not indicated that the resident was receiving hospice care while a resident of the facility. Record review of Resident #49's Comprehensive Care Plan, dated 12/24/2024, reflected the resident was admitted to hospice related to CVA and one of the interventions was to help the resident access hospice services. Observation and interview with Resident #49 on 01/22/2025 at 2:00 PM revealed Resident #49 was in her bed, awake. it was observed that there was a suction machine (medical device that is primarily used for removing mucus or saliva) under the resident's bed. In an interview with LVN B on 01/22/2025 at 2:16 PM, LVN B stated Resident #49 was in hospice and hospice was the one who provided the suction machine. Observation and interview with MDS Nurse G on 01/24/2025 at 8:30 AM, MDS Nurse G stated the MDS Assessment should reflect if a resident had an external catheter, was using oxygen, and was in hospice. She said the medical diagnosis, physician order, MDS, and the care plan should match to provide an understandable overview of the resident's current condition. She said, by doing so, correct goals and interventions would be provided. She opened Resident #20's profile and saw that the resident had orders for the external catheter (Purewick) and for oxygen therapy. MDS Nurse G also checked the resident's care plan and saw that the resident was care planned for the external catheter and oxygen therapy. She then checked the resident's MDS and saw that the external catheter and oxygen were not triggered. MDS Nurse G also checked Resident #49's profile and saw that her MDS was not triggered for hospice. She said if the residents were not properly assessed, the proper care and needs would not be met. She said she was not responsible for Resident #20 and #49's MDS but she would audit the residents entrusted to her and check if they were properly assessed. Observation and interview with MDS Nurse H on 01/24/2025 at 8:47 AM, MDS Nurse H stated the MDS was not just for reimbursement but a means for the staff to properly assess the residents. She opened Resident #20's MDS and saw that the resident was not triggered for external catheter and oxygen. She also opened Resident #49's MDS and saw the resident was not triggered for hospice. She said all the above mentioned should be reflected in the MDS. She said she would review the residents MDS and would make the appropriate changes. She said she would also audit the MDS of the other residents. She said if the residents were not properly assessed, the needs would not be met and there could be confusion in the provision of care. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated the MDS to reflect the current condition of the resident. He said if there was no accurate assessment, there could be a misunderstanding about the care needed. He said coordinate with the DON and the MDS Nurses to evaluate the situation. Record review of facility policy, Resident Assessment Policy and Procedure revised January 12, 2020, revealed Purpose: To assess each resident's strengths, weaknesses, and care needs. To use this assessment data to develop a person-centered comprehensive plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible . Procedure . The assessment process includes direct observation, the medical record, as well as communication with the resident and direct care staff across all shifts.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #20) two residents reviewed for Incontinent Care. The facility failed to ensure that Resident #20's external catheter was properly stored on 01/22/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings included: Review of Resident #20's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old resident admitted to the facility on [DATE]. Resident #20 was diagnosed with overactive bladder. Review of Resident #20's Quarterly MDS Assessment, dated 12/24/2024, reflected the had a moderate impairment in cognition with a BIMS score of 11. Resident #20's Quarterly MDS Assessment did not indicate that the resident was using an external catheter. Review of Resident #20's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with elimination and one of the interventions was to assist with PureWick as per orders and resident request. Review of Resident #20's Physician Order, dated 01/22/2025, reflected purewick drain On Night Shift. Observation and interview with Resident #20 on 01/22/2025 at 10:15 AM revealed Resident #20 was in her bed, awake. It was observed that a PureWick system was at the resident's bedside. The resident said she used it every night. In an interview with LVN B on 01/22/2025 at 10:47 AM, she stated Resident #20 used a urine collection system called PureWick. She said the PureWick urine collection system was an external catheter used by the resident every night. She said the nurse would connect the external catheter to a tube connected to the collection canister. She went inside resident's room and saw the tube where the external catheter was on the floor. She said the connector tube should not be on the floor because the germs from the floor would be on the tube and could possibly transfer also to the catheter that would have a direct contact with the resident's perineal (area between the legs) area. She said she did not notice the tube connector of the PureWick was on the floor when she did her round. She said she would be mindful during rounds that the tube connector used to collect urine was properly stored to prevent infections. In an interview with ADON A 01/23/2025 at 1:39 PM, ADON A stated the tube connector should be cleaned and properly stored when not in use to prevent cross contamination and urinary tract infection. She said the expectation was for the staff to properly store the tube connector. She said the whole PureWick urine collection system should not be on the floor for the same reason. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated Resident #20 used an external catheter every night. She said the collection system had a connecting tube to put the external catheter. She said every part of the urine collection system should be kept clean to prevent cross contamination and urinary tract infection. She said the connecting tube should be stored properly when not in use. She said the expectation was for the staff to clean the connecting tube when the external catheter was disconnected and store it properly. She said she would educate the staff the importance of ensuring the connecting tube was properly stored. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated whatever the resident was using should be kept clean to prevent infection. He said the expectation was for the staff to do the right procedure. He said he was not a clinician and would let the DON handle the issue about the external catheter. Record review of the facility's policy, Perineal Care/Incontinent Care Restorative Policy revised 04/2012 reflected Provisions . 2. Set up clean field . 10. Remove gloves and wash hands or alcohol gel and re-glove hands. Policy for external catheter requested on 01/23/2025 at 2:07 PM via email to the Administrator but was not provided during exit.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #49 and Resident #64) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #49's suction machine and the Yankauer suction tip (oral suctioning tool used to remove fluid and secretions from the airway) connected to it was properly stored on 01/22/2025. 2. The facility failed to ensure Resident #64's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to the oxygen concentrator was properly stored on 01/22/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #49's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 was diagnosed with disturbances with salivary secretions. Record review of Resident #49's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #49's Comprehensive Care Plan, dated 12/24/2024, reflected breathing pattern as one of the resident's problem list and one of the interventions was to monitor lung sounds, cough, and character of sputum. Observation and interview with Resident #49 on 01/22/2025 at 2:00 PM revealed Resident #49 was in her bed, awake. It was observed that there was a suction machine on the floor, under the resident's bed. A Yankauer was connected to the tubing of the suction machine and the tubing was coiled around the machine. The Yankauer was not properly stored. When asked about her suction machine, the resident did not reply. In an interview with LVN B on 01/22/2025 at 2:16 PM, LVN B stated Resident #49 was in hospice and hospice was the one who provided the suction machine. She said the suction machine should not be on the floor and the yankauer should be bagged when not in use. She said the issue was not if the resident was using it or not but if it was kept clean in case the resident needed it. 2. Record review of Resident #64's Face Sheet, dated 01/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #64 was diagnosed with shortness of breath. Record review of Resident #64's Quarterly MDS Assessment, dated 01/13/2025, reflected the resident had a Brief Interview for Mental Status score of 99 indicating the resident was not able to finish the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #64's Comprehensive Care Plan, dated 12/02/2024, reflected the resident had an impaired gas exchange and of the interventions was to auscultate lung sounds. Record review of Resident #64's Physician Orders, dated 11/13/2024, reflected O2 at 2 LPM by NC PRN shortness of breath FOR O2 SAT <90%. Observation on 01/23/2025 at 1:11 PM revealed Resident #64 was not inside the room. An oxygen concentrator with a nasal cannula connected was observed at the resident's bedside. The nasal cannula was hanging on top of the oxygen concentrator and was not bagged with the prongs of the nasal cannula almost touching the floor. Observation and interview with LVN C on 01/23/2025 at 1:19 PM, LVN C stated the Resident #64 was in hospice and hospice was the one who provided for the oxygen concentrator. She said the resident did not usually use the oxygen. She said even though the resident was using it as needed, the nasal cannula should be properly stored when the resident was not using it. LVN C disconnected the nasal cannula and threw it in the trash can. She said if the nasal was exposed, germs from the oxygen concentrator or even the floor could transfer to the nasal cannula and might cause infection. In an interview with ADON A on 01/23/2025 at 1:39 PM, the ADON A stated the nasal cannula and the yankauer should be bagged whenever the resident was not using it to prevent cross contamination and eventually infection. She said the nasal cannula was inserted to the nose and the Yankauer to the mouth, and if they were dirty, it was just like introducing germs to the inside of the body. She said the expectation was for the staff to ensure the equipment used for respiratory care were properly stored. She said she would do an in-service about bagging the nasal cannula and the Yankauer when not in use. In an interview with the DON on 01/23/2025 at 1:57 PM, the DON stated the nasal cannula and the yankauer were supposed to be in a bag when the resident was not using it to prevent cross contamination and respiratory infections If the staff would prefer to have them near the residents, they should be stored properly. She said the expectation was for the staff to be mindful and make sure the nasal cannula and the yankauer were kept clean and bagged when the residents were not using them. She said she would conduct an in-service about respiratory care. In an interview with Hospice Nurse I on 01/24/2025 at 8:56 AM, Hospice Nurse I stated when a resident was admitted on hospice, hospice would provide some equipment that would facilitate comfort during end-of-life care. She said hospice would provide, but the facility was responsible in taking care of the equipment. Just like the nasal cannula and the yankauer of the suction machine, the staff of the facility should make sure that they were clean and properly stored to prevent cross contamination and respiratory infection. In an interview with the Administrator on 01/24/2025 at 10:09 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. He said he was not a clinician but would coordinate with the DON on how to go forward about the respiratory care issue. Record review of the facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection 2001 MED-PASS, Inc. revised October 2012, reflected Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment . 7. Store the circuit in plastic bag, marked with date and resident's name.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse. Resident #1 was cognitively impaired and had diagnoses of Alzheimer's. Resident #1 was sexually assaulted by a visitor whom she did not know, on 11/28/24. An IJ was identified on 12/05/24. The IJ template was provided to the facility on [DATE] at 4:04 PM. While the IJ was removed on 12/06/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm to resident health or safety because all staff had not been trained on the plan of removal. This failure placed residents at risk for abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's electronic face sheet, printed 12/05/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's without behavioral disturbance, psychotic disturbance, or mood disturbance (the most common cause of dementia). Record review of Resident #1's Quarterly MDS Assessment, dated 10/18/24, reflected she had a BIMS score of 03 indicating severe cognitive impairment. Functional abilities section GG revealed Resident#1 needed assistance with eating, oral hygiene, partial moderate assistance with toileting, shower, bathing. Record review of Resident #1's care plan revised 10/07/24 reflected the following, Cognitive Deficit: Decision-making with interventions that included, monitor for any changes, or decline in cognitive, administer meds as ordered, allow ample time for task completion, assess for unmet need (pain, hunger, thirst, toileting), Decreased stimulation as needed, Encourage simple leisure activities. Wandering/At risk for elopement, Bracelet alarm for alarm door with interventions: Bracelet alarm for alarm doors, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, document all incidents of wandering, keep picture of resident at front desk, make sure all staff are aware of elopement risk, reorientation to person, place, and time prn. Review of Resident #1's clinical record did not reveal an incident report regarding sexual abuse. Interview on 12/05/24 at 11:15 AM with the Administrator stated there was a Male Visitor who did not know Resident #1 and had never visited her. The Male Visitor began coming to the facility about 4 weeks ago to visit Resident #3 once a week. The Administrator stated according to the video provide Resident #1's roommate, Resident #4's responsible party, on Thanksgiving Day (11/28/24) around 12:30pm the Male Visitor entered the facility. He was seen on camera interacting with Resident #1. Resident #1 and the Male Visitor interacted then went to her room to make out. They left her room, and he went to visit Resident #3's , and Resident #1 followed him. He alerted the nursing staff that Resident #1 was following him, and they intervened. He left Resident #3's room and went back to the Resident #1's room looking for her. The Male Visitor found Resident #1 in the hall, and they went back to Resident#1's room and were seen on camera disrobing. The Vale Visitor pulled the curtain and was seen after a few minutes naked and getting dressed and telling the resident to get dressed. The Male Visitor told Resident#1 he would be back on Tuesday( (12/03)24, and they could do it again. The Male Visitor left the building. The Social Worker was contacted on Friday ((11/29/24) by Resident #4's responsible party about the incident. Police were called and Resident #1 was taken home by her family. Resident #1 had not returned to the facility Wednesday (12/04/24). The Administrator stated staff were in-serviced on 11/29/24 on identifying the Male Visitor and notifying law enforcement should the Male Visitor be seen on the property. The Administrator stated staff was in-serviced on 11/30/24, 12/01/24 and 12/2/24 regarding identifying sexual abuse. The Administrator initiated safe surveys with residents on 11/30/24 and 12/01/24. The Administrator stated the facility did not have a procedure for tracking visitors in the building. The Administrator stated the door to Resident #1's room was typically closed therefore staff would not have thought it was unusual that the door was closed. The Administrator stated he was informed about the incident on 11/29/24 and a self-report was completed and investigated by a state surveyor on 12/01/24. The Administrator was asked to provide the internal investigation however stated the details of the investigation had not been type up and completed yet because he had not had time. The internal investigation notes were not provided. The Administrator stated the facility did not have a visitor log and did not track visitor upon entry. The code to the front door was posted outside the front door which allowed visitors access to the building at any time. Review of safe surveys with residents initiated on 11/30/24 and 12/1/24. Review of the in-service regarding identifying the male visitor and contact law enforcement and the administrator dated 12/29/24. Review of in-service regarding identifying sexual abuse dated 11/30/24, 12/01/24 and 12/2/24. Review of the video provided by Resident #1's room mate, Resident #4's responsible party, to facility on 12/01/24 was undated which and was 15 minutes an 44 seconds long revealed while in Resident #1's room the Male Visitor asked Resident #1 if she ever pulled the curtains for privacy and proceeded to kiss her and rub his hands over her body as they stood body to body near Resident #4's side of the room. The Male Visitor pointed at Resident #4's bed and asked how old she was, and Resident #1 stated I do not even know who she is. The Male Visitor stated he was going to see Resident #3, who was his mother, but before leaving told Resident #1 she was so beautiful. The Male Visitor proceeded to kiss and rub his hands over Resident #1's body and then told her he would come back in a little bit. The Male Visitor was seen closing the door of Resident #1's room and kissing and rubbing Resident #1 while body to body again. The Male Visitor told Resident #1 You're so sexy. You did well. and continued kissing and rubbing Resident #1's body while standing body to body. Resident #1 and the visitor were no longer in the room and another male appearing to be a resident entered the view of the camera and walked out of the room. The Male Visitor and Resident #1 returned to the room however the camera view does not show the room of the door being closed. The Male Visitor directed Resident #1 to close the blinds. The Male Visitor closed the curtains at 9 minutes and 38 seconds on the video and was seen coming back from behind the curtain fully naked at 10 minutes and 12 seconds on the video. The Male Visitor dressed and stated to Resident #1 I will see you on Tuesday and we can do a repeat. You can have me again. The Male Visitor reiterated to Resident #1 multiple times I will see you on Tuesday. I will see you in five days. The Male Visitor asked Resident#1 to repeat when she was going to see him again and when she stated 5 days he stated You got it. Good job. Give me a high five. The Male Visitor asked Resident #1 How many days would it be before you see me? Resident #1 responded 10 and the Male Visitor stated 5 and Resident #1 repeated 5. The Male Visitor reminded Resident #1 to get dressed and left the room. Resident #1 was seen fully naked and began getting dressed at 14 minutes and 8 seconds into the video. Review of the 2nd video titled angle 2 provided by Resident #4's responsible party was undated and was 6 minutes and 30 seconds long. At 2 minutes and 33 seconds the Male visitor was seen undressing and Resident#1 was seen fully nude. The curtains were closed, and the Male visitor was seen naked at 3 minutes and 34 seconds and Resident #1 was seen laying in bed. At 6 minutes and 01 second Resident #1 was seen naked and began getting dressed. Record review of the summary provided by the police department, undated, revealed: Sexual Assault Investigations at Assisted living Facility [City and state], December 4,2023- On November 28,2024 at approximately 2:44pm, [City/state] Police department responded to [facility name] at [facility address] in reference to a visitor possibly having sexual contact with a resident. Responding officers learned a family member of a resident installed a security camera inside that resident's room. The family member reported that while reviewing video from the camera, they observed an unknown male engaging in some type of sexual act with the family member's roommate. The family was aware of the lack of mental capacity of the roommate and contacted staff. [Facility name] staff contacted law enforcement and were able to identify the male wo was a visitor at the facility as [Male Visitor], age and of state/ city]. [name of police department] criminal investigation division began investigating the allegation immediately. The resident was moved from the facility by family. The Facility was asked to contact the policed department if [Male Visitor] returned. Detectives received information that [Male Visitor] would be back at the facility on December 4, 24, and set up surveillance. [Male Visitor] was taken into custody at 11:04 PM on December 4, 24 for a warrant obtained for indecent assault. After speaking with [Male Visitor], charges were also filed for aggravated sexual assault. [Facility name] has been cooperative throughout the investigation. They will be conducting an internal investigation, but at this time it is not believed that there are other victims. Interview on 12/06/24 at 5:25 AM with CNA A revealed she was made aware that there was an incident of sexual abuse in the facility however she was not informed of the details. She stated on 11/30/24 she was provided information regarding the Male Visitor and informed that if she saw him to contact law enforcement and the Administrator. CNA A stated she also completed a in- service regarding identifying sexual abuse. CNA A revealed visitors did not have sign in to visit residents. CNA A stated she did not received training on changes to how visitors accessed the building. Interview on 12/06/24 at 5:28 AM with RN B revealed she was informed on11/30/24 to alert the Administrator and law enforcement if she saw the Male Visitor. RN B stated she completed an in-service regarding recognizing sexual abuse however she had not completed any training regarding how visitors accessed the building. RN B stated staff were not currently tracking visitors in the building and visitors did not have to sign in to visit. Interview on 12/06/24 at 5:32 AM with RN C revealed she worked with Resident #3 and was informed that the family member was involved in the sexual assault however she did not know the details. RN C stated she had never seen the Male Visitor in the building and stated he only recently began visiting and calling the facility for Resident #3. RN C stated she was informed that if she saw the Male Visitor to contact law enforcement and she completed a training on sexual abuse. She stated she had not completed training regarding any changes to how visitors accessed the building however she did know that there was a person sitting near the front door who was screening visitors as they entered due to the sexual assault. RN C stated Resident #3 was verbal however due to cognitive ability would not likely be able to complete an interview. Interview on 12/06/24 at 5:36 AM with CNA J revealed she was informed about the sexual abuse in the facility and showed a picture of the Male Visitor and was told to contact law and the Administrator if she saw him. She stated she received training on sexual abuse and was informed that visitors would begin using a sign in sheet moving forward. Attempted interview on 12/06/24 at 9:35 AM with Resident #4 revealed she was unable to answer questions due to cognitive ability. A family member spoke through the camera and provided her contact information. Interview via phone on 12/06/24 with Resident #4's family member revealed she informed the facility about the sexual abuse. She stated she was not sure why staff kept asking Resident #4 about the incident because she did not know anything. She stated she was concerned that a random resident kept walking in the room and making Resident #4 uncomfortable. The family member stated she would like for the staff to be more aware of who was going into the rooms. Review of the facility policy ABUSE, NEGLECT AND EXPLOITATION AND MISAPPROPRIATION OF RESIDENT PROPERTY revised February 12, 2020 revealed: The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents. 1.Resident Rights. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of resident's property, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. 2.Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. An Immediate Jeopardy was identified on 12/05/24. The Administrator and DON were notified of the Immediate Jeopardy on 12/05/24 at 4:04 PM. The IJ template was provided to the facility on [DATE] at 4:04 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of removal was accepted on 12/05/24 at 9:54 AM and revealed the following: [Facility name}] 3rd Draft Plan of Removal for F600 submitted on 12/05/24. What corrective action will be taken for those residents found to have been affected by the deficient practice; o The facility immediately notified the police of the allegation. o The resident was taken to an acute care hospital for sane exam by the resident's family member per police request. o After the resident's sane exam was completed at the acute care hospital, she went home with her family member and remains there today. o The perpetrator was immediately identified by the Administrator and Licensed Social Worker after viewing video that was provided by a family. The video was in place per the AEM programs. o The location of the perpetrator was unknown and all staff were trained on how to identify him and what actions needed to take place if he appeared on the property again. o A door monitor was initiated to monitor all visitors entering the facility to identify him if he enters the facility. The monitor was in place 24 hours a day. o The facility cooperated with the [City name] Police Detective and contacted the perpetrator to arrange a care plan meeting. This was an attempt to identify when he would return to the facility as he resides in [State name]. The care plan meeting was scheduled for 10:00 am on 12/04/24. The perpetrator arrived and the [City name] Police Department immediately arrested him, and he is currently in the [City name] City Jail after being charged with Aggravated Sexual Assault. o All staff were trained multiple time on sexual abuse, their responsibilities, and how to identify sexual assault. How other residents with the potential to be affected by the same deficient practice will be identified; o All residents have the potential to be affected by this practice. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur; o On 12.06.24, the Administrator will implement a visitor log at the entrance to the facility for visitors to sign in and out. o On 12.06.24, the Administrator will place signage at the entrance of the facility that describes the requirement for the visitor to sign in and out. o Beginning on 12.06.24 all staff will be trained on this new visitation requirement. This training will be provided by their respective supervisors. o In the event that [Resident #1] request to be return to the facility the facility will take the following actions: o Resident #1's care plan will be updated to include: ? Increase visual checks of [Resident #1] to every hour by a designated staff member. ? If [Resident #1's] door to her room is found to be closed, staff will check resident status to ensure safety. ? If [Resident #1] is observed to be exhibiting overly friendly behavior with another resident or visitor, staff will redirect, as able. ? [Resident #1] will be assessed upon admission any additional care plan updates will be completed to ensure we meet the psychosocial needs of [Resident #1]. o [Resident #1's] representative will be informed of the right to have video surveillance in her room per Authorized Electronic Monitoring. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur; i.e., what program will be put into place to monitor the continued effectiveness of the system changes; o A designated staff member will make hourly rounds in the facility round and identify visitors in the facility. o This designated staff member will then review the visitor log to ensure the visitor has completed the log. If it is found the visitor has not, then they will be provided education on the requirement and complete the log. Monitoring is as follows: Observation on 12/06/24 at 10:20 AM and review of the visitor log dated 12/06/24 revealed visitors were signing the visitor log as they entered the building. Observation on 12/06/24 10:21 AM at of the signage outside the facility front door revealed it informed visitors of the requirements to be allowed in the building by staff and to complete the sign in sheet. Review of staff in- service completed 12/06/24 regarding visitor requirements. The In- service revealed all visitor would complete a sign in log. Staff were to report anything suspicion and a designated staff would make hourly rounds to ensure all visitor completed the sign in sheet. In the instance that a visitor is found not have completed the sign in sheet the visitor would be educated on the requirement and directed to complete the sign in sheet. Interviews on 12/06/24 between 10:20 AM- 11:15 AM with LVN D, MA E, CNA F, CNA G, and CNA H, revealed staff were trained on visitor requirements. Staff revealed visitors would be allowed access to the building by staff and would need to complete a sign in sheet. Staff revealed a designated staff member would complete hourly rounds to ensure all visitors signed in and would be educated on the new policy if they were not signed in. Interview on 12/06/24 at 11:25 AM with the Administrator In Training revealed he had been tasked to complete the hourly checks to ensure all visitors were accounted for and would educate and direct anyone who had not completed the sign in sheet to do so. The AIT stated he was designated to check the sign in sheet and verify that each visitor was with their family member and had completed the sign in sheet. The AIT stated if a visitor is found that had not completed the sign in sheet the visitor would be educated on the requirement and directed to complete the sign in sheet. An IJ was identified on 12/05/24. The IJ template was provided to the facility on [DATE] at 4:04 PM. While the IJ was removed on 12/06/24 at 12:00 PM the facility remained out of compliance at a scope of isolated and a potential for more than minimal harm to residents' health or safety because all staff had not been trained on the Plan of Removal.

Based observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of one resident (Resident #1) reviewed for Incontinent Care. The facility failed to ensure CNA G did not use the same wipes used to clean Resident #5's lower abdomen to clean the resident's perineal area on 12/03/2024. This failure could place residents at risk of cross-contamination and development of urinary tract infections. Findings include: Record review of Resident #5's Face Sheet, dated 12/03/2024, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 was diagnosed with chronic kidney disease (loss of kidney function) and overactive bladder (frequent feeling of needing to urinate). Record review of Resident #5's Comprehensive MDS Assessment, dated 10/08/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment reflected Resident #5 was frequently incontinent for both bowel and bladder. Record review of Resident #5's Comprehensive Care Plan, dated 10/09/2024, reflected the resident was at risk for problems with bladder and bowel elimination and one of the interventions was to provide assistance as needed. Observation on 12/03/2024 at 9:17 AM revealed CNA G was about to do incontinent care for Resident #1. CNA G put on a pair of gloves and prepared the things needed for incontinent care. CNA G raised the bed and removed the resident's blanket and pillows and put them on the resident's recliner. She pulled the resident's dress up, unfastened the brief, and pushed it between the resident's legs. CNA G pulled some wipes and cleaned the resident's lower abdomen. After cleaning the resident's lower abdomen, she used the same wipes to clean the resident's front part. She did not get new wipes to clean the front part. In an interview with CNA G on 12/03/2024 at 9:33 AM, CNA G stated she used the front to back technique when she cleaned Resident #1's front part. CNA G said she pulled some wipes to clean the resident's belly and front part. She said she folded the same wipes used to clean the belly before using them to clean the resident's front part. She said she should have thrown the wipe away after each use to prevent the microorganisms from the belly to go to the front part. She said what she did could cause a urinary tract infection. She said she should be attentive of how she did incontinent care because the resident would be at risk for infection. She said they had in-services for incontinent care but she was not able to apply it. In an interview with ADON A on 12/03/2024 at 1:27 PM, ADON A stated the wipes should be discarded after every stroke and not be reused because it could cause cross contamination and probable infection. She said the expectation was for the staff to do incontinent care the right way which was using one wipe per stroke and then discard it. She said she would initiate an in-service as soon as the interview was over. In an interview with the DON on 12/03/2024 at 3:18 PM, the DON stated the wipes should not be folded for reuse during incontinent care. The wipes should be discarded with every stroke to prevent urinary tract infection. She said the expectation was for the staff to remember and practice the proper way of incontinent care. She said she would do an in-service for staff doing direct care and would do a one-on-one in-service with CNA G. In an interview with the Administrator on 12/03/2024 at 4:06 PM, the Administrator stated improper cleaning of the resident could cause infection. He said the expectation was for the staff to do the right procedure for incontinent care. He said he was not clinical and would let the DON handle the issue about improper incontinent care. Record review of the facility's policy, Perineal (area between the thighs) Care/Incontinent Care Restorative Policy revised 04/2012 reflected Policy Statement: Staff will perform perineal/incontinent care with each bath and after each incontinent episode . Provisions . 5. Start at waistband and clean upper abdomen, middle abdomen (lift folds), lower abdomen using side to side motion. (ONLY USE ONE WIPE PER SWIPE.) . 8. For female patient/resident . a. Separate the labia and wash downward (down the center of labia), then downward on each side of the labia using a different peri wipe with each stroke.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents environment remained free of accident and hazards for 2 of 6 residents (Resident #12 and #97) reviewed for accident and hazard free environment. The facility failed to ensure a water leak in Resident #12's bathroom was properly repaired, and the Resident had an accident as a result of the continued water leak. Resident #12 had a hematoma to the front right side of head and a and a bruise to her right arm. The facility failed to prevent employees from bringing their personal dogs into the facility and allowed them to roam unsupervised in the facility's courtyard, which resulted in Resident #97 sustaining an injury. These deficient practices could place the residents at risk for harm, or serious injury. The findings were: A record review of Resident #12's face sheet dated 12/08/23 reflected an [AGE] year-old female admitted on [DATE] with Diagnoses which included: Parkinson's disease (nervous system disorder), muscle weakness, and lack of coordination. Review of Resident #12's quarterly MDS assessment, dated 10/31/23, reflected resident had a BIMS of 13 (cognitively intact), and the Resident required assistance to perform ADL care. Review of Resident #12's Care Plan dated 11/15/23, reflected the resident was care planned for falls and the intervention included Resident at Risk for Falls resident safety will be maintained. Assist resident with toileting needs as needed. A record review of Resident #12's consolidated order dated 12/08/23 reflected additional diagnoses, including rheumatoid arthritis, restless legs syndrome. A record review of the Nurse Notes for Resident #12, dated 11/23/23 by RN L, reflected, 11/23/2023 At about 2am, this Nurse was notified by the assigned CNA that this resident was on the floor. This Nurse observed resident sitting on the floor in the resident's restroom by the commode. Resident stated that she slipped because of wet floor around the commode. Upon assessment, this nurse observed a hematoma to the front right side of head; skin tear to the right arm, and bruise to the right arm. Skin tear cleaned with normal saline, pat dry and sterile strip applied. NP notified; STAT skull series and right arm x-ray ordered. PRN pain medication administered. Vital signs obtained; temp=98.2, hr=63, 02=95%, bp=152/99. SON notified A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by RN L reflected, [PRN (as needed) Administration] 11/23/2023 02:57 AM acetaminophen 500 mg tablet (ACETAMINOPHEN) 1 tablet by mouth every 4 hours As Needed PAIN A record review of the Nurses Notes for Resident #12, dated 11/23/2023 by LVN M reflected, 11/23/2023 F/U (follow-up) related to fall in previous shift, Skull series and x ray to right arm is performed and waiting for results. Right arm bruised and seen 2 skin tears with steri strips and hematoma to right side of forehead. A record review of the Nurses Notes for Resident #12, dated 11/27/2023 by RN L reflected, 11/27/2023 X-ray results collected. Impression shows negative result. A record review of Wound Care Treatments for Resident #12, dated 11/27/23 by LPN /LVN R reflected, Start: 11/27/23 Skin Tear 1 time per day Skin tear to right forearm- clean with normal saline, pat dry, apply xeroform dressing and cover with dry protective dressing until it resolved Dx : Laceration without foreign body of right forearm, initial encounter In an interview on 12/05/23 at 12:25 PM with Resident #12, she stated her toilet had been leaking and she reported it to staff. She stated the Maintenance Director came to fix it, but he only caulked it. She stated the leaking started again, and she told her son about it and he reported it. She stated the bruise on her face was due to a fall she had in the bathroom, which was a result of her bending over to keep her clothes from getting wet from the water on the floor. She stated she lost her balance and fell . She stated her face hit the wall and she landed on her arm. She stated her arm had a dark bruise on it, but she was healing and there was only dark reddish/purplish bruising around the edge of what she said had been a much larger area. She stated staff came to help her up and they checked her out and helped her to bed. She stated they had X-rays taken and she had not broken anything. She stated she did not have to go to the hospital. She stated after her fall, the Maintenance Director came back to fix the leak again, and there hadn't been any more leaks. In an interview on 12/08/23 at 10:27 AM with Resident #12's family member, he stated that stated he did not know about the leaky toilet until after the resident's fall. He stated he talked to the Administrator about the leak and was told by him that they had re-caulked the base of the toilet; however, the toilet started leaking again, and the resident told the family member about her leaking toilet. The family member stated he had contacted the Administrator to let him know that the toilet was leaking again. He stated the Administrator followed up with him, after the fall to let him know that the seal had been replaced and there should be no more leaks. He stated the resident's fall was around Thanksgiving, but he could not recall the exact date. He stated the resident had not said anything else about the toilet leaking. A record review of Resident #97's face sheet dated 12/08/23 reflected a [AGE] year-old female admitted on [DATE] with Diagnoses which included: Dementia (mental impairment), Weakness of gait and mobility. Review of Resident #97's quarterly MDS assessment, dated 10/12/23, reflected resident had a BIMS of 10 (moderately cognitive), impaired vision, and required touching assistance with most ADLs. Resident required partial/moderate assistance with shower/bathe self and lower body dressing. Review of Resident #97's Care Plan dated 10/18/23, reflected resident was a fall risk and interventions including Assessing the environment to maximize safety. In an interview on 12/05/23 at 11:44 AM with Resident #108 (BIM: 15) he stated he had concerns with dogs running around outside in the courtyard unsupervised. He stated that he would like to go outside some days when it was nice, but he cannot because there were dogs running around, unsupervised, and he did not want to be harmed by them or have an injury as a result of them. He stated that the dogs had been roaming the Resident courtyard since he had been admitted to the facility on [DATE]. Observation on 12/05/23 revealed a medium sized black dog (poodle) was observed roaming the facility's only courtyard, unsupervised. On 12/06/23, two dogs were observed roaming around the facility's only courtyard unsupervised. One of the dogs was the same from the previous day and the other was a medium sized dog that was a pit bull mixed with another breed. Both dogs weighed approximately 50 to 60 LBS each. During the Survey Resident council meeting on 12/06/23 at 3:00 PM, seven of the nine Resident (Residents #97, #99, #96, #5, #58, #18, #16) voiced concerns for the dogs roaming around the courtyard most of the week unsupervised, because they were fearful of the dogs jumping up on them and causing them to fall or sustain an injury. During the Resident council meeting, Resident #97 stated she had an incident with the pit bull while she was out in the courtyard, and it resulted in her requiring first aid. An interview on 12/07/23 at 9:37 AM with Resident #97, she stated she could not remember when she got the skin tear from the dog. She stated she just remembered she was outside in the courtyard. She stated it was not a small dog, it was one of the two dogs who play in the courtyard. She stated she did not complain to anyone about the dogs because they were sweet dogs, and she did not fear them. She stated she only went to the nurse because she noticed her arm was bleeding and she tried to wipe the blood away with a tissue, but it continued to bleed. She stated she went to the nurse for help and the nurse asked her what happened. She stated kept a notebook of events to help her refer to what happened each day because she would forget. She looked in her book to see if she wrote anything on 11/22/23, which was the day she sustained the scratch. She had documented the event with the dog. She stated she believed it was the brown and white dog because the black one is more calm. She stated she could not really be sure. She then left her room and asked another resident if he remembered which dog, she said scratched her and he said the brown and white one. Her notation in the notebook read, [DATE] Wed. Got a scare from the dog, so they had to really do it up right. I will live. In an interview on 12/07/23 at 09:56 AM with Resident #40, he stated he and Resident #97 sat at the table together for meals. He stated she told them that the brown and white dog was jumping up a lot and she scratched her and caused her to arm to bleed, so the nurse had to fix her up. He stated she did not seem upset, just surprised. He stated she did not get an infection or anything from the scratch. He stated she said she was outside in the courtyard when the dog scratched her. In an interview on 12/07/23 at 11:39 AM with Resident #97's family member, she stated she was told that Resident #97 went out to play with the dogs and one of them jumped up on her while playing with her and accidentally scratched her arm. She stated they told her that the scratch broke the skin and they cleaned the area and put a bandage on it. She stated she came to the facility the next day, 11/23/23, to see her mother and she saw that her arm was clean and there was a folded square of gauze with a piece of clear tape across it, covering the scratched area. She stated the area was small, so she felt better about it, after seeing it. She stated her mother had told her about the two dogs a while ago and she spoke of them with excitement and said they were very playful. She stated the resident asked her to buy tennis balls, so she could throw them around while playing with the dogs. She stated she was not concerned about her mother's safety at the facility or around the dogs. In an interview on 12/07/23 at 12:46 PM with LVN N, she stated Resident #97 told her that the dog was playing with her out in the courtyard and the dog jumped up on her and scratched her on the elbow. She stated the injury was just a small scratch and the skin was slightly raised, and it was bleeding, not a lot, but it was bleeding. She stated she treated the wound by washing it with soap and water, then she bandaged it. She stated she then called the physician, the resident's family member, and she reported it to the Administrator and DON. She stated she did not witness the accident. In an interview on 12/07/23 at 10:37 AM with the Resident #31, she stated the residents had not complained about the dogs. She stated they just talked about the dogs being playful and always jumping around. She stated she did not know if anyone ever reported a complaint or concern about the dogs to staff. She stated the only staff who knew what the residents said about the dogs, was the Activities Coordinator. An interview on 12/07/23 at 10:50 AM with the Activities Coordinator, she stated she had been bringing her dog to the facility for about a year. She stated the brown and white dog was her dog. She stated she would bring her dog on Mondays, Wednesdays, and Fridays. She stated the dog was usually either with her, in her office or outside in the courtyard. She stated she did not ask permission to bring the dog to the facility. She stated she knew that the Administrator loved dogs and he never told her that she could not bring the dog to the facility. She stated the dog had been fully vaccinated. She stated residents had not complained about the dog. She stated they usually just commented on the dog's activities, which they observed through the window. She stated she took the dog to the rooms of the residents who enjoyed seeing her. She stated she thought it was good for the residents because they seemed to light up when dogs were in the building. An interview on 12/07/23 at 11:22 AM with the Administrator, he stated they had a decade-long history of dogs being at the facility. He stated the two dogs observed, had been coming for at least a year. He stated the staff talked to him about bringing the dogs to the facility. He stated the dogs were puppies when they started coming to the facility, so they grew up there. He stated none of the residents had ever expressed any complaints or concerns about the dogs to him. He stated the dogs' owners told him the dogs were fully vaccinated (verified). He stated he had never been concerned about the residents' safety around the dogs. He stated he was not aware that some residents felt uncomfortable going to the courtyard. He stated had he known, he would have made accommodations because the residents came before the dogs. He stated a possible risk of the presence of the dogs in the facility, would depend on the dog, and if the dog showed aggression. He stated if a dog showed aggression toward residents, they would not be allowed at the facility. He was aware that Resident #97 was scratched by one of the dogs. He stated his understanding was that the resident was outside playing with the dog. He stated the feedback from the residents had always been positive. He stated the residents loved the dogs because they are loving, and the residents like to watch them play. In an interview on 12/07/23 at 10:00 AM with the Administrator, he stated he had no policy regarding employees bringing their pets into the facility, he stated he had no discussions with the employees regarding bringing pets into work, and the facility had no requirements for employee's pet to meet prior to gaining approval to bring pets into the facility. In an interview on 12/08/23 02:46 PM the Social Worker , she stated she had been bringing her dog for about eight months. She stated she did not bring her dog every day. She stated she brought her dog sporadically at first and then more regularly. She stated the dog was fully vaccinated. She stated she did not ask permission because she was told the facility had been pet friendly for years. She stated having pets in the facility was pretty much encouraged by the Administrator. She stated residents would say that they enjoyed watching the dogs play from their windows, especially when they were small puppies.

Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1 the prescribed quantity of fentanyl patches as ordered by the physician. This deficient practice could affect all residents who receive medication from the facility and place them at risk for negative side effects, decline in health, hospitalization , or death . Findings included: Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] Resident #1's diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), chronic heart failure, chronic pain syndrome, rheumatoid arthritis (immune system attacks healthy cells in your body causing painful swelling), lack of coordination, muscle weakness, polyneuropathy (malfunction of many peripheral nerves throughout the body causing a pins-and-needles sensation, numbness, burning pain, and loss of vibration senses), and poisoning by other opioids accidental (unintentional). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS reflected Resident #1 received scheduled opioid pain medication. Record review of Resident #1's Care Plan, dated 05/17/23, revealed Resident #1 had a care area for pain, with the intervention of administering pain medication as ordered. There was a care area which included Resident #1 received fentanyl transdermal patch and the interventions included: obtain pain history onset, intensity, frequency; obtain resident's pain tolerance and attempt to maintain pain tolerance level; and reassess interventions with any changes in response to pain or pain medication and with every assessment. Record review of Resident #1's physician's orders revealed an order for fentanyl (a potent synthetic opioid drug used for pain relief) 25 mcg/hr transdermal patch (fentanyl) 1 patch 72hr transdermal every 72 hours on 1 time per day DX: Pain, unspecified with a start date 10/01/22. Record review of Resident #1's physician's orders revealed naloxone (a medicine that rapidly reverses an opioid overdose) 4mg/actuation nasal spray (Naloxone HCL) 1 spray nasally as needed adverse effect of opioid use 1 actuation in 1 nostril x's 1 and may repeat every 3 minutes as needed. DX: Poisoning by other opioids, accidental (unintentional), initial encounter with start date 06/08/23. Record review of Resident #1's Medication Record for June 2023 revealed Resident #1 received a fentanyl patch on 06/01/23, 06/04/23, and 06/07/23. Record review of Resident #1's nurse's notes, dated 06/08/23 at 11:13 AM, revealed LVN A documented naloxone order injection updated to spray per [Nurse Practitioner] Electronically Signed by [ADON] 06/08/23 10:48 AM as per NP (nurse practitioner), to send her hospital. CN (certified nurse) spoke to family [family member] and as per family preferences to [hospital]. CN called 911 and EMS team is arrived in 5 minutes, and she sent out with med list, face sheet and recent labs. Record review of Resident #1's hospital paperwork, dated 06/08/23, revealed Resident #1's diagnosis included ARF (Acute Renal Failure), Hyponatremia (the sodium level in the blood is below normal), UTI (Urinary Tract Infection), Diastolic Echo (Echo in 82022 EF (ejection fraction) 55-60%), Afib (type of abnormal heartbeat), AMS (altered mental status), Jaundice (a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat)/Transaminitis (an elevated level of certain liver enzymes), and Chronic pain/ RA (rheumatoid arthritis). The hospital paperwork revealed nurse's notes dated 06/08/23 at 12:09 PM stated Limited ROS (Review of Systems- an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced.) otherwise however patient was noted from the facility to have 2 transdermal fentanyl patches on with her MAR from the outside facility showing only supposed to be on 1 patch every 72 hours. In an interview on 06/09/23 at 3:23 PM, Resident #1's FM stated Resident #1 was hospitalized on [DATE] and the hospital nurse told her that resident was overdosed because she was admitted into the facility with two fentanyl patches. Resident #1's FM stated when they saw Resident #1 in the hospital, she was very lethargic and was unable to have a conversation. The FM stated this was not her normal baseline. In an interview on 06/12/23 at 10:45 AM, the NP stated multiple nurses reported that Resident #1's behavior had changed, and she seemed lethargic. She stated she assessed Resident #1 on 06/08/23. The NP stated Resident #1's skin was yellow, she had slurred speech, and her face was drooping. The NP stated Resident #1 received fentanyl patches and she thought maybe she had been overly medicated, so she ordered Narcan (naloxone). She stated after Resident #1 received the Narcan, she was more alert and was able to speak. The NP stated after Resident #1 was more alert, Resident #1 stated she was in pain, so she gave orders to send her to the ER. In an interview on 06/12/23 at 10:54 AM, LVN A stated it had been reported by staff that Resident #1's behavior had changed. She stated the NP assessed Resident #1 on 06/08/23. LVN A stated the NP had concerns that Resident #1 could have opioid overdose, so gave an order for naloxone, via nasal cavity. She stated after Resident #1 was provided the naloxone and the NP gave an order to send her out to the ER. LVN A stated she did provide the fentanyl patch on 06/07/23 and placed it on her right arm. She stated there was one already there and she removed it but did recall how she disposed of it. She stated they were allowed to either flush it down the toilet and or put it in the red disposal box on the medication cart. LVN A stated a lot of times she has the ADON to watch while she throws away the patch because it is best practice, but that day she was busy and did not have time to get the ADON. LVN A stated the DON asked her about this situation as well because Resident #1's FM reported Resident #1 had two patches at the hospital. LVN A stated on 06/07/23 there was only one patch on her arm. She stated the only explanation she could think of as to why Resident #1 had two patches is that maybe one fell off in the bed and one of the CNAs saw it and put it back on. LVN A stated there had not been any CNAs reporting a patch fell off. In an interview on 06/12/23 at 1:44 PM, the DON stated on 06/09/23 Resident #1's FM had reported she felt Resident #1 was overly medicated because she had two fentanyl patches on arm when she admitted to the hospital. She stated she immediately started an in-service on 06/09/23 about ensuring there is only one patch. The DON stated she did review the hospital paperwork for Resident #1 and saw that she admitted into the hospital with two patches. She stated she did review Resident #1's diagnosis from the hospital paperwork and this error did not contribute to her underlying health issues. The DON stated due to this situation she had changed the policy, which would require two nurses to verify the old patch was disposed of and the new patch was applied. The DON stated the risk to the resident is they could have an overdose. Record review of the facility's policy titled Documentation of Administration and Removal of Narcotic Transdermal Patches, undated, The Narcotic Transdermal Patches are powerful, Schedule II narcotics used to manage moderate to severe pain. Although available in other dosage forms, when used in the form of an extended?release transdermal patch it confers pain relief to individuals over a 72?hour period. Customarily, the patch is applied externally to the individual, left intact for 72 hours, and then replaced with a new patch. 4. Remove the patch 72 hours after application. This should be done at the same time every 72 hours. 7. Apply patch to non-irritated skin such as chest, back, flank or upper arm. 13. Documentation requirements: a. Documentation of patch placement q shift. b. Removal of old patch BEFORE placement of a new patch. c. Removal of old patch must be witnessed by 2 nurses and documented on the narcotic control sheet.14. Removed patches must be folded inward, medication to medication, and placed in the original sheath/package. a. Used patches are to be disposed according to the current facility policy regarding disposal of narcotic drugs. b. Dispose in secured pharmaceutical waste container per appropriate medical waste management regulations. c. Patches may not be disposed of in Sharps containers in the resident's room. They must remain under lock and key until destroyed or rendered unusable per current facility policy.

Based on observation, interview and record review, the facility failed to notify the resident representative and the resident's physician, when there was significant change in resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. LVN B failed to notify the responsible party/resident representative and the resident's physician when Resident #1 fell from her bed on 05/22/22, which resulted in a fracture of the left medial femoral condyle (knee area), failed to place the incident on the 24-hour report for ongoing monitoring on 5/22/22, and failed to document any assessments of the resident post fall on 5/22/22. LVN B completed late entry notes 06/02/22 to document fall that occured on 05/22/22. DON completed late incident report on 5/31/22 to document fall for 5/22/22. This failure could place residents at risk of not having their responsible party, physician and oncoming staff notified of changes, which could result in a delay in medical intervention and a decline in health. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 04/22/22, reflected an admitted [DATE]. Resident #1 had a BIMS score of 99 indicating she was not able to complete the interview (not interview-able). The resident required assistance with transfers only. Resident #1's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan dated 06/02/22 reflected the resident required limited assistance by 1 staff for transfers. Interview with the family representative on 6/13/2022 at 02:10 PM revealed, No one notified me of the fall. She found out about the fall due to her having a camera in Resident #1's room and she went back to look at footage. She saw CNA A transferring Resident #1 from bed to chair and that Resident #1 fell while CNA A was assisting her. Record review on 06/13/22 at 05:13 PM revealed 13 photographs taken by a camera in Resident #1's room sent by a family representative. The first picture was time stamped 05/22/2022 at 07:46 AM. CNA A was assisting resident out of bed. Resident #1's face is clear on the photograph. The second photograph dated 05/22/2022 at 07:46 AM shows CNA A lifting the resident under her armpits when transferring. Third photograph dated 05/22/2022 at 07:47 AM shows CNA A lowering Resident #1 to the floor. The sixth photograph dated 05/22/2022 at 07:49 AM shows Resident #1 sitting on floor leaning up against bed. Review of Resident #1's nurse's notes did not reflect any documentation about a fall on 05/22/22 or notification to the family or physician. Late Entry note regarding fall added on 06/02/22, LATE ENTRY: @ 0715 on 5/22/22, this CNA was in 100 hall, checking blood sugar, CNA A came to this nurse for help getting up this resident. CNA A states she was trying to get up this resident from bed to chair, then she could not put on chair and she slowly put her on floor. This nurse went with her to room observed resident was sitting on the floor next to bed and chair. CN assessed for pain and no pain voiced and no pain expression noted. Assisted resident back to chair with CNA's help. Resident went to dining room for breakfast after that. Vital signs stable. RP, daughter made aware on 5/30/22, ADON Mani, DON, and Administrator notified on 5/31/22. Review of incident reports did not reflect any documentation regarding a fall for Resident #1 on 05/22/22 or previous. Incident report reviewed dated 5/31/22 regarding Resident #1. Revealed that type of incident was fall and slide to floor. Incident date/time 5/22/22, 0730AM.There was no apparent injury. Roommate is unable to communicate. Resident #1 Cognitive status is severely impaired. Description of incident states, the CNA was in 100 hall, checking blood sugar, CNA A came to this nurse for help getting up this resident. CNA states she was trying to get up this resident from bed to chair, then she could not put on chair and she slowly put her on floor. This nurse went with her to room observed resident was sitting on the floor next to bed and chair. CN assessed for pain and no pain voiced and no pain expression noted. Assisted resident back to chair with CNA's help. Resident went to dining room for breakfast after that. Vital signs stable. RP, daughter, ADON Mani, DON, and Administrator notified. Comments POC reviewed. Resident had an assisted fall, where staff member lowered her to the floor. At the time of the incident, there was no injury noted. Two days post assisted fall, resident complain of pain to left ankle obtained with no dislocation or fracture noted. Post X-ray, resident demonstrated swelling and continued pain. X-ray to left foot and venous doppler obtained with no fracture or [CONDITION(S)] noted. X-ray of left leg then obtained, also with no fracture or dislocation noted to left femur, foot, knee, or tibia/fibula. Because of continued pain/swelling, resident sent to ER for further evaluation. ER x-rays returned with 1. Generalized osteopenia. 2. A questionable acute nondisplaced fracture of the medial cortex of the medial femoral condyle. 3. Small left knee joint effusion. Resident returned from ER with a brace to left (should be leg) and follow up appt scheduled with ortho on 6/1. Will continue to monitor for pain. Resident placed on bed rest until further instruction from ortho. Interview on 06/16/2022 at 09:49 AM, CNA A revealed, that she did not realize she didn't wear one until after surveyor showed her picture of her and Resident #1. She stated, I must have forgot to wear one. I always wear one. She confirmed there is no gait belt in the picture of her and Resident#1. She also confirmed she was trained to use gait belt before incident and was retrained after the incident and the gait belt is to help prevent falls. Interview with LVN B on 6/15/2022 at 12:38 PM, revealed CNA A got LVN B to help her with Resident #1. Resident #1 was sitting on the floor. LVN B stated, I checked her. She wasn't crying. I assessed her. She was ok at that time. She was normal at that time. Did not state any pain at that time. We both moved her to chair. She stated, she forgot to report it to anyone. She wrote it down and totally forgot to report it to anyone. LVN B did not remember until Resident #1 family representative asked her about the fall. She then reported it to DON and physician. LVN B stated she was trained on their policy previously and was written up and retrained after incident. Interview with DON on 6/16/2022 at 11:53 AM, revealed the DON was originally told about Resident #1 having pain from the family representative. At that point, she called it in to HHSC as an injury of unknown origin. LVN B was off for a few days, so initially did not know about fall. When LVN B came back to work she notified the DON of the fall. LVN B told DON that she forgot to report and document the fall. DON stated, I truly think she just forgot to report it. The DON stated that the reason it is important to report falls is, if we don't have incident report, we can't investigate what happened to prevent further incidents and family need to be kept in the loop so they can trust us. There are several people that are involved in trainings. The DON is one of them. The facility provides annual skill fairs, verbal training, show you, and show us, and observations with check off list for skills. Record review of SG Clinical Skills Fair 2021, dated 07/13/2021 reflected, .FALLS- all falls are to be documented. Include .what MD or NP you spoke with and any orders .the name of the family member you spoke with .fall huddle form should be completed and given to the ADON .Certificate of Completion presented to LVN B for the completion of SG Clinical Skills Fair 2021. Record review of Notice of Warning dated 5/31/22 reflected, LVN B failed to complete an incident and accident report and make the appropriate notifications after a resident's fall. . The facility's policy Incident/Accident reporting: Reportable incident protocol dated 2/12/2020 revealed, Unusual events, accidents, and occurrences will be reported, documented, and investigated to determine what changes, if any, need to be initiated within the facility. The facility's policy Change of Condition dated 2/12/2020 revealed, .acute change of condition is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains .the nurse notifies the responsible physician utilizing appropriate channels and chain of command .notify physicians in the following order .a) attending physician .patient families, guardians, or other appropriate people are to be contacted where there is a significant change in a patient's condition .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Residents # 1) of four residents reviewed for transfers. CNA A failed to transfer Resident #1 safely when she failed to use a gait belt and lifted the resident under her armpits when transferring her from the bed to the wheelchair which resulted in a fracture of the left medial femoral condyle (knee area). These failures could place residents who require transfer assistance at risk for a fall injury. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 04/22/22, reflected an admitted [DATE]. Resident #1 had a BIMS score of 99 indicating she was not able to complete the interview (not interview-able). The resident required assistance with transfers only. Resident #1's active diagnoses included Hypertension, Alzheimer's Disease, Anxiety disorder, and [CONDITION(S)] Disorder. Record review of Resident #1's care plan dated 06/02/22 reflected the resident required limited assistance by 1 staff for transfers. Interview with family representative on 6/13/2022 at 02:10 PM revealed, No one notified me of the fall. She found out about the fall due to her having a camera in Resident #1's room and she went back to look at footage. She saw CNA A transferring Resident #1 from bed to chair and that Resident #1 fell while CNA A was assisting her. Record review on 06/13/22 at 05:13 PM, revealed 13 photographs taken by a camera in the resident's room sent by family representative. The first picture is time stamped 05/22/2022 at 07:46 AM. CNA is assisting resident out of bed. Resident #1's face is clear on photograph. The second photograph 05/22/2022 at 07:46 AM shows CNA A is lifting the resident under her armpits when transferring and no gait belt seen around Resident #1. Review of Resident #1's nurse's notes did not reflect any documentation about a fall on 05/22/22 or notification to the family or physician. Late Entry note regarding fall added on 06/02/22, LATE ENTRY: @ 0715 on 5/22/22, this CNA was in 100 hall, checking blood sugar, CNA A came to this nurse for help getting up this resident. CNA A states she was trying to get up this resident from bed to chair, then she could not put on chair and she slowly put her on floor. This nurse went with her to room observed resident was sitting on the floor next to bed and chair. CN assessed for pain and no pain voiced and no pain expression noted. Assisted resident back to chair with CNA's help. Resident went to dining room for breakfast after that. Vital signs stable. RP, daughter made aware on 5/30/22, ADON Mani, DON, and Administrator notified on 5/31/22. Review of incident reports did not reflect any documentation regarding a fall for Resident #1 on 05/22/22 or previous. Incident report reviewed dated 5/31/22 regarding Resident #1. Revealed that type of incident was fall and slide to floor. Incident date/time 5/22/22, 0730AM. There was no apparent injury. Roommate is unable to communicate. Resident #1 Cognitive status is severely impaired. Description of incident states, the CNA was in 100 hall, checking blood sugar, CNA A came to this nurse for help getting up this resident. CNA states she was trying to get up this resident from bed to chair, then she could not put on chair and she slowly put her on floor. This nurse went with her to room observed resident was sitting on the floor next to bed and chair. CN assessed for pain and no pain voiced and no pain expression noted. Assisted resident back to chair with CNA's help. Resident went to dining room for breakfast after that. Vital signs stable. RP, daughter, ADON Mani, DON, and Administrator notified. Comments POC reviewed. Resident had an assisted fall, where staff member lowered her to the floor. At the time of the incident, there was no injury noted. Two days post assisted fall, resident complain of pain to left ankle obtained with no dislocation or fracture noted. Post X-ray, resident demonstrated swelling and continued pain. X-ray to left foot and venous doppler obtained with no fracture or [CONDITION(S)] noted. X-ray of left leg then obtained, also with no fracture or dislocation noted to left femur, foot, knee, or tibia/fibula. Because of continued pain/swelling, resident sent to ER for further evaluation. ER x-rays returned with 1. Generalized osteopenia. 2. A questionable acute nondisplaced fracture of the medial cortex of the medial femoral condyle. 3. Small left knee joint effusion. Resident returned from ER with a brace to left (should be leg) and follow up appt scheduled with ortho on 6/1. Will continue to monitor for pain. Resident placed on bed rest until further instruction from ortho. Interview on 06/16/2022 at 09:49 AM, CNA A revealed, that she did not realize she didn't wear one until after surveyor showed her picture of her and Resident #1. She stated, I must have forgot to wear one. I always wear one. She confirmed there is no gait belt in the picture of her and Resident#1. She also confirmed she was trained to use gait belt before incident and was retrained after the incident and the gait belt is to help prevent falls. Interview on 06/16/2022 at 12:06 PM, PT C revealed that if a gait belt is it not used, both the employee and resident could be injured due to poor mechanics and not having a good handheld location on the residents body. Interview on 06/16/2022 at 11:42 AM , the Director of Rehabilitation revealed that, It is important to use gait belt to have better grasp of patient and help have a sturdier hold of patient. If they do go down it is much easier to control with gait belt and can cause more injury to patient and to staff when they bear hug the patient. Interview on 06/16/2022 at 11:53 AM, the DON revealed, the expectation is that gait belts are used with residents that require assistance in transfers. CNA A confirmed she did not wear a gait belt during transfer. There are several people that are involved in trainings. The DON is one of them. The facility provides annual skill fairs, verbal training, show you, and show us, and observations with check off list for skills. The use of gait belt is to prevent injury. Record review of a Provider Investigation Report for Resident #1, dated 06/02/22, had CNA A statement which did not include whether gait belt was on Resident #1 during transfer. Record review of Skill Competencies dated 10/27/2021 reflected: .Skills .Personal Safety and Emergency Care .Body mechanics .change of condition .fall prevention and fall response .stand, pivot, transfer bed to chair .OSHA Lift Program Skills Check-off Sheet .Gait/Transfer belt .When manual assist is required for general supervision, possibly limited assistance .help a resident get up/sit down .transfers between bed and wheelchair .Competency Date 10/27/2021 .Observation signed trainer and CNA A. New Skills Competencies dated 6/01/22 completed and signed by CNA A. The Facility's policy titled, Assisting the Resident with Transfer using Gait Belts, dated 02/12/2020, reflected, Staff will use appropriate methods to assist residents with transfer needs while using a gait belt in accordance with standard practice guidelines .if the residents starts to fall; Grasp gait belt with both hands .