Every finding on record at Grace Care Center of Henrietta

A complaint investigation was conducted on 03/4/26 for intakes #1073184, 1073358. Census 21.Abbreviations/AcronymsNone used.Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1 and #2) of 2 dumpsters located outside of the facility. The facility failed to prevent two of the facility's dumpsters located outside of the facility, lids were closed when not in use and trash was not on the ground from overflow of the dumpsters being full. These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals. Findings included: During an observation on 03/04/25 at 11:30 a.m., dumpsters #1 and #2 were observed located outside the facility at the back of the property. Dumpster #1 and #2 was observed with the lids open, unable to be closed due to bagged garbage stacked above rim. There were 11 bags of trash and 5 cardboard boxes on the ground outside of the dumpster. During an interview on 03/04/36 at 1:30 p.m., CNA A said staff had to pile trash bags on top of the already full dumpsters and hoped they stayed on top of bags already in the dumpsters or trash bags would be left on the ground beside the dumpsters. CNA A states the facility needed to get the dumpsters emptied, because it made the facility look trashy. CNA A said that she had voiced her concerns to Administrator, but nothing had been done. CNA A said dumpsters have not been emptied in weeks. During an interview on 03/04/26 at 1:45 p.m., the Maintenance Director stated he was responsible for the trash on the ground near the dumpster but had been busy with other work. The Maintenance Director stated the dumpsters were over-flowing due to not being collected by sanitation for lack of payment. The Maintenance Director said he used his trailer and pickup to take trash to landfill but had not done so in several days; but planned to take a load today. The Maintenance Director stated trash on the ground and lids not being able to close could invite pests to the facility grounds and possibly into facility. During an interview on 03/04/26 at 2:10 p.m., the Administrator stated that waste bill had been paid and the trash dumpsters would be emptied this week. The Administrator stated that overflowing dumpsters could attract pests. Environmental Policy requested on 03/05/36 at 4:00 p.m., facility did not provide policy.

Based on interview and record review, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are complete and accurately documented for 4 of 4 residents (Residents #1, #2, #4, and #7) whose records were reviewed for blood glucose monitoring and insulin administration.The facility failed to ensure insulin administration via insulin pump and blood sugar results were documented as ordered on the Medication Administration Record, dated September 2025, for Residents #1, #2, #4, and #7. These failures could place residents at risk for inaccurate clinical health records. The findings included: Record review of the facility list of diabetic residents who received insulin, dated 09/30/25, revealed the names of four current residents. Two of the residents had insulin pumps and the other two residents received insulin injections. Record review of Resident #1's admission Record, dated 10/02/2025, revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included type 1 diabetes mellitus (autoimmune disease which results in little to no insulin production), type 2 diabetes mellitus (the body does not use insulin effectively and results in high blood sugar levels), and presence of insulin pump. Record review of Resident #1's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:- Order dated 7/19/2025 for Novolog Injection Solution 100 unit/ml (Insulin Aspart) 230 units in the afternoon every 3 days for Insulin Pump related to diabetes mellitus with diabetic chronic kidney disease, scheduled for 1400 (2:00 PM) was not initialed by the nurse on 9/06/25 and 9/09/25.- Order dated 1/12/2025 to announce meal intake into the Insulin Pump 5 minutes prior to eating meal and no later than 5 minutes after starting to eat. Do not announce meal if more than 30 minutes after Resident #1 started eating related to type 1 diabetes mellitus (autoimmune disease which results in little to no insulin production), scheduled 3 times daily was not initialed by the nurse for 0725 (7:25 AM) on 9/04/25, 9/06/25, 9/09/25, 9/12/25; for 1155 (11:55 AM) on 9/06/25, 9/09/25, 9/12/25, and for 1655 (4:55 PM) on 9/06/25.- Order dated 1/08/2025 to check bbg before meals tid by Insulin Pump three times a day related to diabetes mellitus with diabetic chronic kidney disease scheduled for 0730 (7:30 AM), 1130 (11:30 AM), and 1630 (4:30 PM) was not initialed by the nurse for 7:30 AM on 9/04/25; for 7:30 AM, 11:30 AM, 4:30 PM on 9/06/25 and 9/09/25; and for 7:30 AM and 11:30 AM on 9/12/25. Record review of Resident #2's admission Record, dated 10/02/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included type 1 diabetes mellitus (autoimmune disease which results in little to no insulin production) and type 2 diabetes mellitus with hyperglycemia (the body does not use insulin effectively and results in high blood sugar levels - with a result of high blood sugar levels). Record review of Resident #2's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:- Order dated 7/19/2025 for Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution pen-injector 2 mg/3 ml (Semaglutide) - Inject 1 mg subcutaneously in the morning every Friday related to type 2 diabetes mellitus with hyperglycemia until 10/02/2025 weekly for 4 weeks, scheduled for 0700 (7:00 AM) was not initialed by the nurse on 9/12/2025.- Order dated 7/19/2025 for Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution pen-injector 2 mg/3 ml (Semaglutide). Inject 0.5 mg subcutaneously in the morning every Friday related to type 2 diabetes mellitus with hyperglycemia until 9/11/2025 weekly for 4 weeks, scheduled for 0800 (8:00 AM) was not initialed by the nurse on 9/04/2025.- Order dated 8/21/2025 to announce meal intake into the Insulin Pump 10 minutes prior to eating meal and no later than 10 minutes after starting to eat, with meals related to type 2 diabetes mellitus with hyperglycemia was not initialed by the nurse for 0800 (8:00 AM) on 9/04/25, 9/06/25, 9/12/25; for 1200 (12:00 PM) on 9/06/25 and 9/12/25; and for 1700 (5:00 PM) on 9/06/25 and 9/09/25.- Order dated 8/27/2025 for blood sugars tid before meals and record before meals for hypoglycemia was not initialed by the nurse for 0700 (7:00 AM) on 9/04/25, 9/06/25, and 9/12/25; for 1130 (11:30 AM) on 9/06/25 and 9/12/25; and for 1630 (4:30 PM) on 9/06/25 and 9/09/25. Record review of Resident #4's admission Record, dated 10/02/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (the body does not use insulin effectively). Record review of Resident #4's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:- Order dated 4/16/2025 for Lantus SoloStar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) - Inject 30 unit subcutaneously in the morning related to type 2 diabetes mellitus with chronic kidney disease, scheduled for 0700 (7:00 AM) was not initialed by the nurse on 9/06/25, 9/09/25, and 9/12/25.- Order dated 2/03/2023 for fsbs check with sliding scale coverage before meals for fsbs related to Type 2 diabetes mellitus with diabetic chronic kidney disease with sliding scale was not initialed by the nurse and did not have blood sugar levels documented for 1130 (11:30 AM) on 9/06/25, 9/09/25, 9/12/25, and 9/15/25; and for 1630 (4:30 PM) on 9/09/25 and 9/12/25.- Order dated 4/03/25 for Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) - Inject as per sliding scale if:150 - 209 = 1 unit;210 - 269 = 2 unit;270 - 329 = 3 unit;330 - 389 = 4 unit;390 - 449 = 5 unit;Notify Dr. [name] of greater than 375, Subcutaneously before meals and at bedtime for diabetes.The nurse did not document the blood sugar levels, the amount of insulin units if administered, and initial for 0700 (7:00 AM) on 9/06/25, 9/09/25, 9/12/25; for 1130 (11:30 AM) on 9/06/25, 9/099/25, 9/12/25, 9/15/25; for 1630 (4:30 PM) on 9/06/25, 9/09/25, 9/12/25, 9/17/25; and for 2000 (8:00 PM) on 9/05/25, 9/12/25, and 9/23/25. Record review of Resident #7's admission Record, dated 10/02/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (the body does not use insulin effectively). Record review of Resident #7's Medication Administration Records, dated 9/01/2025-9/30/2025, revealed the following:- Order dated 10/04/2024 for fasting bbg every morning, scheduled for 0600 (6:00 AM) related to type 2 diabetes mellitus, did not have a documented blood sugar level and was not initialed by the nurse on 9/06/25 and 9/09/25.- Order dated 10/28/2024 for Toujeo SoloStar Subcutaneous Solution Pen-injector 300 unit/ml (Insulin Gargline) - Inject 60 unit subcutaneously in the morning related to Type 2 diabetes mellitus with diabetic neuropathy, scheduled for 0800 (8:00 AM), did not have a documented blood sugar level and was not initialed by the nurse as administered on 9/06/25, 9/09/25, 9/12/25. In an interview on 9/30/25 at 4:48 PM, C.N.A. A stated she was also a medication aide. She stated she worked the day shift (6 AM - 6 PM) on 9/12/25 and the nurse scheduled to work that day called in. She stated RN D came to the facility the morning of 9/12/25. C.N.A. A stated she had given the residents their medications and RN D would have given the insulin injections to two residents - Resident #4 and Resident #7. During an interview and record review on 9/30/25 at 5:10 PM, the DON reviewed the eMARs for Resident #4 and Resident #7 and stated the nurse had not signed off that she had administered the insulin injections for Resident #4 or Resident #7 on 9/12/25. The DON stated both residents had scheduled insulin orders for the morning. She stated there was no way of knowing whether or not the nurse administered the insulin injections. The DON stated the nurse may have done it and just not signed off on the eMAR. The DON stated she had started employment in the facility on 9/23/2025 and did not know who had been scheduled to work prior to that date, as a working nursing schedule had not been kept with documented staff changes. In an interview on 10/01/25 at 1:41 PM, Resident #7 stated she was a diabetic and received an insulin shot in the morning and pills at bedtime. Resident #7 stated she had not missed any insulin injections in the morning. She stated, They know I need it. Resident #7 remembered RN D and stated she had given her insulin shots in the morning and thought she had given the shots twice (on 2 occasions). In an interview on 10/01/25 at 2:47 PM, LVN B stated she was employed in the facility on and off for 2 years and usually worked on the day shift 6 AM - 6 PM. LVN B stated the night shift nurse did the fsbs for the residents with injectable insulin - Resident #4 and Resident #7. She stated the morning of 9/12/2025 the night shift nurse should have done the fsbs for the 2 residents by 6 AM and documented the results on the eMAR. LVN B stated the 2 residents with the insulin pumps (Residents #1 and #2) had their blood sugar checked by a continuous glucose monitor later when served breakfast. She stated the nurse pressed the button for the meal and slid the administer insulin option by touch screen. In an interview on 10/02/25 at 11:53 AM, RN C stated she was employed with the facility since the end of July 2025. RN C stated the nurses checked the diabetic residents' blood sugars before administering insulin injections. She stated sometimes the night nurse did it and sometimes the day shift nurse did it. RN C stated Residents #1 and #2 had insulin pumps and the continuous glucose monitor was tied into their insulin pumps and would read their blood sugars. RN C stated the nurse took the meal trays to Residents #1 and #2. She stated the two residents received insulin before each meal and at bedtime. RN C stated sometimes she checked Resident #7's sugar in the morning, but other times went by the night shift nurse's reading of the resident's blood sugar. She stated Resident #7 received insulin only in the morning and her insulin was long acting. RN C stated she took Resident #4's blood sugar before giving her insulin as she received sliding scale insulin at breakfast and dinner. In an interview on 10/02/25 at 4:48 PM, the DON stated the expectation for the nurses was that they prepared insulin and documented on the eMAR when insulin was administered just like any other medication. She stated the fsbs results were documented on either the eTAR or eMAR. She stated a possible outcome from not doing so could be elevated blood sugars. The DON stated the insulin pumps would release insulin without the meal being selected but it would be released at a later time. Record review of the facility's Policy and Procedure: Administration of Insulin Therapy, dated 7/01/2025, revealed the following specifications [in part]: I. Policy StatementIt is the policy of (facility name) to administer insulin only upon a licensed practitioner's order to maintain therapeutic blood glucose control. Due to the high-risk nature of insulin, administration requires mandatory safety checks, adherence to proper technique, and compliance with State regulations.II. PurposeTo ensure the safe, accurate, and timely administration of insulin, including basal, prandial, and correctional (sliding scale) doses, to standardize protocols for glucose monitoring and management of acute complications (hypoglycemia/hyperglycemia).III. ScopeThis policy applies to all licensed nursing staff (RNs and LVNs), and to unlicensed personnel (CNAs/Medication Aides) only when administration is specifically delegated by a Registered Nurse and is compliant with (state name) Board of Nursing rules.1. Restriction: In a Skilled Nursing Facility, the administration of injectable medications (including insulin) is typically performed by a licensed nurse.D. Monitoring, Storage, and Documentation.4. Documentation: The administering nurse will document on the MAR:- Insulin Type, Dose, Injection Site, Date, and Time.- BGM result and time immediately prior to insulin administration

Based on observation, interview and record review the facility failed to ensure menus were followed for 2 of 2 meals reviewed for Food and Nutrition Services.1. The facility failed to ensure the menu was followed on 07/27/25 and food substitutions were made for the planned lunch menu.2. The facility failed to ensure the menu was followed on 07/28/25 and food substitutions were made for the planned dinner menu. These failures could place residents at risk for weight loss and compromised nutritional health status. The findings include: 1. Record review of the current resident roster, provided 7/27/25, revealed the facility census was 18. Record review of the resident diet order list, printed 7/27/25, revealed all facility residents received oral nutrition. No residents received nutritional support by feeding tubes. Record review of the weekly planned menus revealed they were issued by the food vendor. The menus were signed by the food vendor's Registered Dietitian on 3/08/2025 and were valid until 3/31/2026. Record review of the planned lunch menu for Sunday, 7/27/25, revealed it consisted of chopped steak, mushroom gravy, mashed potato casserole, multi-color cauliflower, wheat dinner roll, margarine, marbled cheesecake, 2% milk and coffee. Observation and interview on 7/27/25 at 10:02 AM revealed whole kernel corn in a rectangular stainless-steel pan was being heated on the stove top. Observation of the oven's interior revealed a baking sheet with sizzling breaded meat patties. The DM stated the breaded meat patties were pork fritters'' and they were being substituted for the Salisbury steak for lunch. The DM stated she had the Salisbury steak, but she was out of brown gravy to serve with it and would order brown gravy the next day. She stated food was ordered on Monday and Thursday and was delivered on Tuesday and Friday. Observation on 7/27/2025 at 12:31 PM revealed the lunch meal service was in progress in the dining room. There were 12 residents present and seated at the tables. The residents were served and were eating. A white board was mounted to the wall and had the lunch menu written on it: pork fritters; mashed potatoes; corn. 2. Record review of the planned menu for the evening meal on 7/28/25 revealed it consisted of Italian beef sandwich, mixed waffle fries, sauteed peppers and onions, rocky road pudding, 2% milk and coffee. In an interview on 7/28/25 at 4:35 PM, the DM stated turkey bologna sandwiches with lettuce and sliced tomato were being substituted for the beef sandwiches, due to beef roast being too expensive for the budget. The DM stated she had a substitution log, and she proceeded to open a drawer under the island counter and removed a spiral notebook with substituted food items written down. The DM stated she took pictures of the food substitutions and sent them by email to the RD Consultant. Observation on 7/28/25 at 4:45 PM revealed the following food substitutions were prepared for the dinner meal:- turkey bologna and cheese sandwiches for the Italian beef sandwiches;- regular French fries for the waffle fries; - Italian blend vegetables for the sauteed peppers and onions for the mechanical soft diets; - zucchini and yellow squash for the pureed diets; - carnival chocolate chip cookies for the rocky road/chocolate pudding. In an interview on 7/29/25 at 9:00 AM, the DM provided the food substitution notebook for review. She stated there was not a documented reason for the food substitutions due to the budget being the reason the substitutions were being made. In an interview on 7/29/25 at 1:39 PM, the DM stated she was working on alternate menus. She stated the food vendor had a program with menu substitutions that would fit into the facility's budget. She stated she was working on sample menus but had not yet submitted them to the RD Consultant for approval. Record review of the DM's menu substitutions notebook revealed handwritten food items that were on the planned menu and the food items that were being served as substitutions. There were no reasons documented for the substitutions. The entries for July 2025 were documented on 7/5/25, 7/7/25 lunch, 7/16/25, 7/17/25 - 2 meals. There were no documented food substitutions for 7/27/25 lunch or 7/28/25 dinner. Record review of the facility's, undated, policy for Menus included documentation [in part]:Policy StatementMenus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.Policy Interpretation and Implementation 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences).2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance .4. The Dietician reviews and approves all menus .6. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived.7. Copies of the menus (as served, including substitutions) are kept on file for reference.8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.9. If a food group is missing from a resident's daily diet (e.g. dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g. calcium supplementation or fortified non-dairy alternatives).10. Menus are updated periodically.11. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them. Record review of the facility's, undated, policy for Substitutions, included documentation [in part]:Policy StatementFood substitutions will be made as appropriate and necessary.Policy Interpretation and Implementation1. The Food Services Manager, in conjunction with the Clinical Dietician, may make food substitutions as appropriate or necessary. The Food Services Shift Supervisor on duty will make substitutions only when unavoidable.2. The Food Services Manager will maintain an exchange list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the Food Services Manager will consult the Dietitian prior to making the substitution.3. Residents' likes and dislikes will be considered when making substitutions.4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution.5. The Food Services Manager will review the substitutions regularly to avoid recurrences when possible.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services.1. The facility failed to ensure Paper towels were available for drying hands at the handwashing sink.2. The facility failed to ensure food was covered and not stored room temperature on the stove top and a shelf above the stove top.3. The facility failed to ensure the residential style chest freezer did not have thick frost build-up on its interior side surfaces.4. The facility failed to ensure opened food item packages were placed in sealed containers and were labeled and dated with a use by date in the refrigerator.5. The facility failed to ensure cooked food items stored in resealable plastic bags were not stored on a sheet pan with a thawing raw pork loin.6. The facility failed to ensure expired milk was not stored in the refrigerator. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings include: Observations and interviews starting on 7/27/25 at 9:55 AM, during the initial tour of the kitchen, revealed the following:- The paper towel dispenser, mounted on the wall by the handwashing sink, was empty. - A rectangular stainless-steel pan, containing whole kernel corn with 3 large mounds/lumps of butter on top of the corn, was uncovered and was positioned on the stove top on 2 gas burners, which were not lit. The side of the pan was cold to touch. - A baking sheet with 11 pieces of raw dough (dinner rolls) was uncovered and positioned on the stainless-steel shelf above the gas oven and grill. Observation and interview on 7/27/25 at 10:01 AM revealed the DM entered the kitchen and washed her hands at the handwashing sink. She walked across the room to the 2-compartment sink and pulled a paper towel from a roll of paper towels on a roll holder mounted to the wall above the second sink compartment. When asked about the paper towel dispenser being empty near the handwashing sink, the DM stated, We haven't been able to get towels for that type of dispenser for a while. Observation on 7/27/25 at 10:02 AM revealed the DM proceeded to turn on the 2 gas burners at a low setting, beneath the pan which contained corn on the stove top. Observation on 7/27/25 at 10:04 AM revealed a residential style chest freezer which contained pails of ice cream and an unopened/sealed plastic bag which contained breaded meat patties. The chest freezer had thick frost build up on the 4 interior sides. Observation on 7/27/25 at 10:06 AM revealed the industrial style stainless steel 3-compartment refrigerator unit contained the following: - A baking sheet with sealed raw pork loin thawing on it was positioned on the bottom shelf. The same metal baking sheet held plastic gallon-sized resealable bags as follow: honey mustard pork loin, dated 7/14/25; sweet potatoes with fluid in the bag with no label and no date; sliced sausage, dated 7/20/25; breaded chicken patties, dated 7/13/25; sliced turkey in gravy dated 7/26/25; sliced ham, dated 7/25/25; and sausage patties, dated 7/27/25. In an interview on 7/27/25 at 10:10 AM, the DM stated all the food in the plastic bags were cooked and they were left over food. She stated the bags were dated when the food was placed in them and did not include use by dates. The DM stated left over food should be used within a week of being cooked. Observation and interview on 7/27/25 at 10:11 AM revealed the wire rack shelf units above the thawing pork loin held containers with food which were not dated or were outdated:- A 5-pound container with sour cream was opened and contained less than 1/3 and was, dated 6/17/25, on the lid. The manufacturer date indicated best when used by 7/20/2025. The DM stated the container of sour cream was dated on the lid when it was received, and it was opened for use during the weekend.- A plastic storage container with a lid had a label identified as scrambled eggs and was dated 7/23/25. - A plastic storage container, dated 7/23/25, was not labeled and appeared to contain white/cream gravy. - An 8-pound carton of potato salad was opened to the air and was not resealed and dated 7/22/25. Observation on 7/27/25 at 10:20 AM revealed the second compartment of the refrigerator held large pitchers with tea, dated 7/20/25, on their lids; an open gallon of milk which was half full, dated 7/20/25, on the lid; and an open 60 ounce bottle with cranberry juice, dated 7/22/25, on the lid. In an interview on 7/27/2025 at 10:28 AM, the DM stated the milk and cranberry juice were opened that morning. Observation on 7/27/25 at 10:28 AM revealed the dry/non-perishable food storage room had wire rack shelves. An open 5-pound container with creamy peanut butter was dated 5/17/25 on the lid. The lid had not been securely replaced on the container and there was a small gap of space between the lid and the top rim of the container. In an interview on 7/27/25 at 10:30 AM, the DM stated the peanut butter had a shelf life of one year, even after the container was opened. She stated the date on the container lid was the received date. Observation and interview on 7/28/2025 at 4:18 PM revealed the cooked food in resealable bags that were stored on the sheet pan with the raw pork loin on the bottom shelf of the refrigerator during the initial tour on 7/27/25 were removed from the refrigerator. The DM stated the bags were contaminated with blood from the pork loin and she had to throw away all the bags with food that were on the pan. She stated two bags with food were outdated. The DM stated the resealable bags were on the shelf above the pork loin but were put on the pan with the pork loin on the bottom shelf. Observation revealed the container with scrambled eggs, dated 7/23/25, remained in the refrigerator. The DM stated she used them to make the pureed eggs for breakfast and she still had a day to use them. Record review of the facility's, undated, policy for Refrigerators and Freezers, included documentation [in part]: Policy StatementThis facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.Policy Interpretation and Implementation7. All food shall be appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes.9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately.10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Record review of the Food and Drug Administration Food Code 2022 specified [in part]:Chapter 3 Food3-202.15 Package Integrity.Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation did involve abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 16 residents (Resident #2) reviewed for abuse or neglect. The facility failed to report to the State Survey Agency allegations of abuse after Resident #2 said CNA B was rough and used profanity. This failure could place residents at risk of not having incidents of abuse and neglect being reviewed and investigated in a timely manner by the facility and the State Survey Agency.The findings include: Record review of Resident #2's face sheet, dated 7/29/2025, revealed [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: dementia (loss of memory, language, problem-solving, and other thinking abilities), chronic pain (persistent pain that lasts longer than 3-6 months), anemia (not enough healthy red blood cells to carry adequate oxygen to the body tissues), diabetes (disease that affects how your body regulates blood sugar levels), schizoaffective disorder (mental health condition), bipolar disorder (extreme shifts in mood, energy, and activity levels), anxiety (repeated episodes of sudden feelings of intense fear or terror) and seizures (abnormal surge of electrical activity in the brain). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed [in part]: Section C - Cognitive patterns Resident #2 had a BIMS score of 13, which indicated the resident was cognitively intact. Section E - Behavior Resident #2 did not exhibit any behavioral symptoms. Section GG - Functional Abilities, Resident #2 required a wheelchair, partial to moderate assistance with eating, dependent with oral hygiene, toileting hygiene, shower/baths, upper/lower dressing and putting on/taking off footwear, and substantial to maximal assistance with personal hygiene. As well as dependent in all transfers, sit to stand, sit to lie, and rolling left to right while in bed. Record review of Resident #2's Care plan, dated 05/29/25, revealed [in part]; At risk for decline ADLs, cognition, and communication. Date initiated 05/29/2025 Intervention: Encourage, remind the resident to ask for help and aid as needed. At risk for pain related to: Left knee and generalized pain. Date initiated 05/29/2025 Goal: Will show signs/symptoms of pain control as evidenced by participation in daily activities. Intervention: Observe non-verbal signs/symptoms of pain to include but not limited to; facial grimacing, guarding, restlessness, agitation. Reposition as needed for comfort and notify nurse. Potential for communication deficit and injury related to minimal hearing deficit. Date initiated: 05/29/2025 Goal: Needs will be anticipated and met by staff as evidenced by being clean, appropriately dressed, and comfortable. Interventions: Allow resident extra time to communicate needs/concerns. Introduce self to resident, explain care/procedure to be performed. Repeat instructions as needed. Do not rush when assisting. At risk for spontaneous fracture related to diagnosis of Osteoporosis. At risk for complications related to Medications. Date initiated: 05/29/2025 Diagnosis of bipolar disorder and is at risk for increased episodes of depression driven behaviors and side effects to medications. Date initiated 05/29/2025 Goal: Will have no reports of increased signs or symptoms of depression and no signs or symptoms or reports of side effects to medication. Interventions: Approach in calm manner, introduce self and explain procedure/care to be provided. Observe for/document increased signs and symptoms of depression to include but not limited to crying, tearfulness, withdrawn, decrease in activity participation, change in appetite, restlessness, negative statements and notify nurse. ADL self-care performance deficit and is at risk for further decline and injury related to vision deficit and generalized weakness. Date initiated: 05/29/2025 Goal: Maintain current level of function in all ADLs and will be free from injury. Interventions: Provide total assistance of 1 person for bathing/showering. Provide total assistance of 1 person for bed mobility. Provide total assistance of 1 person for upper/lower body dressing. Provide extensive assistance of 1 person for eating. Provide extensive assistance of 1 person for personal hygiene/grooming. Provide total assistance of 1 person for toileting. Provide total assistance of 1 person for transfers. Encourage the resident to discuss feelings about self-care deficit. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care. Record review of Resident #2's progress notes, dated 7/29/2025 at 12:28 PM, revealed [in part]: Effective date: 07/25/2025 08:30AM. Documented by LVN A [Recorded as a Late Entry on 07/27/2025 at 1:43PM] Entry states: While administrating medications, Resident #2 stated who was that girl that worked last night? Asked her which one, the nurse or the aid. Asked if she is referring to CNA B. Resident stated yes. LVN A told Resident #2 the CNA Bs name. Resident #2 stated yes that's her, I had a very bad night, CNA B is not nice to me. I asked CNA B to do me a favor, and she told me I don't have to do any favors for you. Resident said what, why? CNA B stated because I don't have to do anything for you're a**. Resident #2 stated to LVN A I just needed to be changed, and CNA B is very rough and throws me around like a rag doll when she changes me and I don't like that, it hurts me. Resident #2 went on to say, Then you know what else she did, I asked CNA B to please not shut my door and guess what she did, she closed the door, I don't like my door closed because I am claustrophobic.I do not want CNA B taking care of me anymore LVN A informed Resident #2 that she would report that to the DON and that it is not acceptable and was very sorry that she was treated that way. Resident #2 thanked LVN A for listening to her and understanding. 09:30 AM, LVN A Notified the DON and RN C weekend nurse of the above information. 10:10 AM, LVN A asked the DON if she would come talk to the resident as Resident #2 was talking about it again to LVN A. The DON, RN C and LVN A went back to Resident #2's room. When the DON asked how Resident #2's night went, Resident #2 stated the above information to the DON and RN C. The DON informed the resident she would handle this issue and talk to CNA B about her concerns. Record review of TULIP on 07/29/25 revealed: The facility called in a Facility-Reported Incident regarding Resident #2's allegations against CNA B from 07/25/25 on 7/29/25. The allegation was Resident Abuse. In an observation and interview on 7/27/2025 at 10:30 AM, revealed Resident #2 was awake in bed, staff present at bedside upon entry into the room. Staff assisted resident with TV remote, left the room. Resident #2 was alert and maintained conversation well. The resident reported she lost track of time and lived at the facility longer than she thought. The resident stated the day staff was wonderful but the other shift (3-11) staff was not great and she related this to a specific night shift CNA B but was unable to recall her name at the time of this interview. In an interview on 7/29/2025 at 9:25 AM, LVN A stated on Friday (7-25-25) during shift report LVN G informed her Resident #2 made a complaint during her shift about care received by CNA B. LVN G stated to LVN A that she handled it with the CNA B and had told her if it happened again LVN G would write her up. LVN A stated LVN G did not report this to the DON or ADMN. LVN A stated during medication pass on 07/25/2025, Resident #2 asked her who was the female aide taking care of her last night. Resident #2 described the staff member to LVN A as being CNA B who provided care the previous shift. Resident #2 reported to LVN A that CNA B was rude and told the resident she didn't have to do her any favors and was rough with brief changes and it hurt her. LVN A stated Resident #2 said she requested CNA B leave the door open when she left the room and then CNA B closed the door, and that Resident #2 stated she didn't want CNA B to provide care for her anymore. LVN A informed the DON of the complaint at this time. LVN A went back into Resident #2's room to follow up on medications and the resident immediately brought up her complaint again. LVN A went to the DON office and requested they go together to Resident #2s room together and address her concern being she has brought it up again and was still upset about it. At the bedside, Resident #2 repeated the same concerns with consistency that she had reported to LVN A. LVN A stated she heard about 2 other complaints regarding CNA B without knowing specific complaints or what residents were involved in. At this time LVN A was unaware if the DON had any further follow up with the complaint after they met with Resident #2 on 7/25/2025. LVN A stated since this complaint, CNA B provided care to the resident the night before. LVN A stated at shift change last night, Resident #2 had not returned from the hospital, but she did share the concerns with the oncoming LVN F, during report. LVN A stated during shift report this morning, there were no reports of concerns with Resident #2's care last night. LVN A reported she visited with the resident this morning and there were no complaints or concerns voiced. In an interview on 07/29/2025 at 9:40 AM, HR stated there were no complaints made to her in the last week regarding any staff being rude, rough or abusive to residents. She stated an employee, CNA B, was recently suspended for 3 days (July 9) while a self-report investigation was completed. After investigation was completed, CNA B was retrained on some skills and there was an in-service to all staff related to the self-report. HR reported CNA B attended all in-service trainings since she was hired in January. In an interview on 07/29/2025 at 11:05 AM, Resident #2 stated all but one staff member treated her with kindness. The resident stated CNA B was rough and flipped her around like a pancake, flipped the covers around and was just rough and mean. The resident denied any issues with any other staff members; she stated they were all supportive and very nice. In an interview on 07/29/2025 at 12:40 PM, the DON stated her start date was 7/21/2025. The DON stated her responsibility if abuse or neglect was reported to her was to report it to the state within 24 hours. She then reported she received 2 grievances, regarding care provided by CNA B and her language, late yesterday' (7/28/2025) and she started to investigate them. She stated one was from Resident #2, complained to the DON and the SW. She stated Resident #2 alleged CNA B was rough with care and when asked told the resident that she didn't have to do her a** any favors. Resident #2 also requested the door remain open, and CNA B intentionally closed the door. The DON stated after she was made aware of these grievances on 7/28/2025 regarding CNA B and how she spoke to the resident and how CNA B was rough during incontinence care. The DON stated she came back to the facility the evening (around 9PM) of 07/28/2025, to discuss the complaints with CNA B, who denied having any trouble with the residents. The DON stated she followed CNA B into the resident's rooms and watched her interaction with the residents, and she felt like there was no fear or uneasiness from the residents. She stated when Resident #2 returned to the facility, CNA B aided with transfer from the cot to the resident's bed as well as performed incontinent care and Resident #2 had no complaint. The DON stated she had not spoken with Resident #2 since this interaction but when she was watching CNA B interact with the residents, she observed her with a soft tone and personality. She stated her expectation was for the nurses and aides to report what they witnessed or were told immediately to her or ADMN. The DON stated she wanted them to write a report about the allegation or incident. The DON stated she also expected staff to report it to her immediately so she could appropriately report to the state survey agency. She stated she was unclear on what self-report constituted. The DON stated negative outcomes that could result from not reporting abuse or neglect would be the abuse would continue, it was degrading, and if it was unresolved, it would snowball and could cause a decline in physical and emotional health of the resident. She stated after a complaint, if an employee then retaliated against the complainant, she reported that would be an elevation in the process. She stated she would have to check the policy, but her initial thought was the employee would at a minimum be suspended pending the investigation and off the clock. She stated she was unsure what the criteria was for immediate termination, but elder abuse wasn't tolerated. She stated she planned to do in-service education on protocols for reporting and abuse, neglect and exploitation policies. The DON stated she was very new to her position as DON in this facility and she would go to RCN and ADMN for guidance. *1st Request for copies of grievances made on 07/28/2025 from the DON who verbalized understanding to provide the documents as soon as possible. In an interview on 7/29/2025 at 2:30 PM, a 2nd request for a copy of the grievances filed on 7/28/2025 was made from the DON, who stated SW was still working on finishing them but expected her to email them to her. In an interview on 7/29/2025 at 3:25 PM, the ADMN provided documents labeled QA Rounds that were completed by the RCN as well as 1 unsigned grievance form, dated 7/25/2025 at 9:00am regarding Resident #2. In an interview on 7/29/2025 at 3:55 PM with the ADMN, DON, and RCN, the DON stated the SW came to her on 7/28/2025 with concerns reported by Resident #2, during her normal visits with them. The RCN stated any claim of abuse is to be report to the state within 2 hours of when it was made. The RCN stated LVN A did not document the conversation with Resident #2 on 07/25/2025, until 07/27/2025 and then the resident told the SW on 7/28/2025. The ADMN reported when she checked the progress notes on Sunday morning (7/27/2025) for the last 24 hours she did not see the entry made by LVN A referring to the statements made by Resident #2. (RCN was able to access the chart during the interview and confirm the late entry was made on Sunday around 1PM.) The DON stated the failure in reporting/communicating the resident complaint from Friday she stated, I didn't perceive it as abuse at the time.I have been here for just about a week and I have been overwhelmed. it was an oversight on my part. The DON then explained how to identify the 5 forms of abuse. The ADMN stated she heard about the grievance on 7/28/2025 late afternoon around 2:30-3:00PM. She stated she made a self-report around 10:30-11:00am today (7/29/2025) and still at that time felt it was more of a grievance. The ADMN looked at her paperwork for the self-report and stated LVN A came to her around noon to follow up regarding the resident's complaint and the ADMN felt like the wording of the grievance was questionable for requiring a self-report and stated she completed the self-report at 12:43 PM. The RCN stated the DON came back to the facility last night to address the grievances and their grievance policy allowed them 5 days to resolve any resident grievance, and this was within the timeline if truly a grievance. The DON stated when she asked the residents about CNA B continuing to provide their care she was allowing the residents autonomy and to participate in decisions involving their care. In a telephone interview on 7/29/2025 at 4:28 PM, RN C stated she started work at the facility last Monday 7/21/2025. She stated she worked last Monday, Wednesday and Friday with the DON. RN C stated LVN A came to her and the DON one of those days and reported Resident #2 reported verbal abuse. She stated they, all 3, went to Resident #2's room and the resident stated CNA B was rough with her in repositioning, used vulgar language, and when asked to do something for her (can't remember exactly what it was but something like moving her pillow or getting her the remote), CNA B told the resident I don't have to do anything for you. RN C stated Resident #2 asked CNA B to leave the door open but she shut the door and Resident #2 felt like it was on purpose. RN C stated after leaving the resident room the DON said she was going to interview CNA B and probably give her a write up. RN C stated she never followed up on if a write up was given or not but she was told yesterday (7/28/2025). In an interview on 7/29/2025 at 4:50 PM, LVN A stated the late entry was made on Sunday (07/27/2027), not on Friday (07/25/2025) in real time. She stated she was the only nurse working Friday (7/25/2025). was very busy and ran out of time. She also stated the facility did not allow any extra hours so staying late to chart was not an option. In a telephone interview on 7/29/2025 at 5:54 PM, the SW stated at around 1PM on 7/28/25 she was informed by CNA E about the complaint Resident #2 had regarding the other night with CNA B that occurred last Thursday (07/24/2025) during the 6p-6a shift. The SW was informed CNA B was being rough and used profanity. The SW stated she and the DON went to the resident's room to investigate and felt it was more of a grievance than abuse at that point, so she did not inform the ADMN or Abuse Coordinator at that time. Record review of the facility's, undated, policy and procedure titled Standards of Conduct revealed [in part]: .Report any suspected violations of laws, regulations, or facility policies to appropriate management. C. Reporting Violations: 1. Any employee who witnesses or suspects a violation of these Standards of Conduct is obligated to report it immediately to their direct supervisor, the Director of Nursing, Human Resources, or the Administrator. 2. Reports can be made confidentially and without fear of retaliation. The facility will investigate all reports promptly and thoroughly. Record review of the facility's, undated, policy and procedure titled Mandatory Reporting Acknowledgement revealed [in part]: I. Purpose: The purpose of this policy is to ensure that all employees of [the facility] are aware of their mandatory reporting obligations regarding suspected abuse, neglect, exploitation, or certain communicable diseases, as required by federal and state laws. All employees, volunteers, and contractors are mandatory reporters under federal and state laws and are required to immediately report any suspected instances of such situations without fear of retaliation. Failure to comply with these mandatory reporting requirements is a serious violation of this policy and applicable laws and will result in disciplinary action up to and including termination of employment. 2. Immediate Reporting: Any employee who has a reasonable suspicion of any of the above reportable incidents must report it immediately upon discovery. Immediately means as soon as the individual becomes aware of the situation, without delay for further investigation. c. External Reporting to Authorities 1. Primary Responsibility: The administrator, director of nursing, or their designated representative is primarily responsible for making the required external reports to the appropriate state and federal agencies. 2. Timelines: External reports will be made within the timeframes mandated by federal and state laws (e.g., 2 hours for serious bodily injury, 24 hours for other allegations, specific timelines for communicable diseases). Record review of the facility's, undated, policy and procedure titled: Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime revealed [in part]: 6. Verbally or non-verbally cursing, vilifying, degrading or threatening physical or emotional harm to an individual receiving services. 7. Any act or omission by an employee, contractor, or volunteer that places an individual receiving services at risk of physical or emotional injury. I acknowledge my responsibility as an employee, contract employee, or volunteer to report abuse, neglect, and exploitation. I understand that i should report any incident that i suspect may be abuse, neglect, or exploitation even if I am not sure. I realize I may be criminally liable for failing to report abuse, neglect, or exploitation. (in-service completed, signed by staff involved, and 07/29/2025) Record review of the facility's, undated, policy titled Abuse Prevention Program, revealed [in part]: Administration will: 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #18) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #18's hospitalizations on 2/27/25-3/04/25, 4/24/25-5/05/25, and 5/28/25-6/09/25 related to urinary tract infection. 2. The facility failed to ensure a care plan was developed to address Resident #18's admission to Hospice care services on 7/03/25. 3. The facility failed to ensure a Significant Change Minimum Data Set Assessment was completed for Resident #18 after the resident had a significant change on 07/11/25. These failures could place residents at risk for not receiving care and services to meet individual needs and a continued decline in health status.The findings include:Record review of Resident #18's admission Record, dated 7/29/2025, revealed an [AGE] year-old female with an original admission date of 10/20/2023, and initial admission date on 9/26/2024, and a current admission date on 6/09/2025. The resident's diagnoses included: cerebral infarction due to thrombosis of unspecified middle cerebral artery (stroke due to a blood clot in the brain); diabetes mellitus type 2 with chronic kidney disease (high blood sugar levels due to insulin resistance and insufficient insulin production with loss of kidney function); hypertension (high blood pressure); atrial fibrillation (irregular heart rhythm); hypothyroidism (thyroid disorder); gastro-esophageal reflux disease (back-flow of stomach acid into the throat); major depressive disorder (depressed mood state), and presence of insulin pump. Record review of Resident #18's Nurses Notes revealed she was hospitalized on [DATE]-[DATE], 4/24/25-5/05/25 and 5/28/25-6/09/25 related to UTI with E.coli (Escherichia coli - intestinal bacteria) - resistant to multiple antibiotics and IV antibiotic therapy. Record review of Resident #18's Nurses Notes, dated 7/04/25, revealed an order for the antibiotic medication Macrobid 100 mg by mouth 2 times daily for 14 days for UTI. Record review of Resident #18's Order Summary Report, dated 7/29/2025, revealed an order, dated 7/03/25, to admit the resident to Hospice services with a diagnosis of cerebral infarction due to thrombosis of unspecified middle cerebral artery. Record review of Resident #18's Significant Change MDS assessment, dated 7/11/25, revealed the resident received antibiotic medication and Hospice care services. The diagnosis of UTI had not been selected in the infection diagnosis section. Record review of Resident #18's comprehensive care plan revealed, it was dated 10/27/2023 and was revised 10/18/2024, the comprehensive care plan had not been updated following the completion of the Significant Change MDS assessment and did not include care plans to address frequent/recurrent UTIs, urinary incontinence, and Hospice care services. During an interview and record review on 7/29/25 at 12:36 PM, the RN Corporate Nurse reviewed Resident #18's comprehensive care plan in the electronic health record. Following review of the resident's comprehensive care plan, the RN stated she did not locate a care plan addressing recurrent/frequent UTIs. The RN reviewed Resident 18's Significant Change in Condition MDS assessment, dated 7/11/2025, and saw the resident was receiving an antibiotic medication. The RN Corporate Nurse stated she was at the facility a few weeks ago and was told at time Resident #18 had frequent/recurrent UTIs and had been hospitalized for IV antibiotics for UTI with resistance to multiple antibiotics. The RN Corporate Nurse stated she was not aware the resident had been admitted to hospice services. She stated the family was considering it when she was at the facility a few weeks ago. The Corporate Nurse did not find a care plan for hospice services in Resident #18's comprehensive care plan. During an interview on 7/29/25 at 12:47 PM, the RN Corporate Nurse called the LVN Care Plan Nurse and placed her on speaker phone. The LVN stated she had only been in the position for 2 weeks. The Care Plan Nurse stated she completed the comprehensive care plans and reviewed them every 3 months. She stated the facility nurses could enter acute care plans between assessment and care plan review dates. She instructed the Corporate RN to look at the resolved care plans. The Corporate RN looked at Resident 18's resolved care plans and stated she did not see an acute care plan or any care plans addressing UTIs. In an interview on 7/29/25 at 1:42 PM, the Corporate RN stated the expectation was for the DON to enter acute care plans and/or care plans addressing new issues as needed between the comprehensive reviews. She stated the charge nurses did not enter care plans into the residents' electronic health records. The Corporate RN stated she would provide a facility policy and procedure for care plans, timing, and revision for review. Record review of the facility's, undated, policy for Care Plans, Comprehensive Person-Centered, revealed the following [in part]:Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation1.The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in a resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required MDS assessment

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility reviewed. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The phone and internet were disconnected, service repair bills/vendors were not paid, and the facility van did not have insurance or current registration tags. The facility failed to provide enough money to purchase the food necessary to follow the menus and to purchase printer supplies. An Immediate Jeopardy was identified on [DATE] at 3:52 pm. The IJ template was provided to the facility on [DATE] at 3:52pm. While the Immediate Jeopardy was removed on [DATE] at 4:36 pm, the facility remained out of compliance at scope of widespread and a severity level of no actual harm with potential for more than minimal harm because the facility needs to take action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and the residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. These failures could place residents at risk of not receiving essential care and services that the facility is responsible for providing. Findings included: During an interview on [DATE] at 9:30 am, the DON said the facility had not had an Administrator since [DATE]. She said: the facility had not been paying vendors. The phones/fax were not working. The staff had to utilize their own cell phones to conduct facility business. The facility is not able to send or receive faxes. A staff member bought a pre-paid cell phone, so the residents were able to call their family and vice versa. The staff went and bought milk, coffee, and hot chocolate for the residents, yesterday [DATE], due to the facility not having any for the residents. The ice machine was rented and was scheduled for repossession next Wednesday, [DATE] for non-payment. The nurses had purchased ink cartridges and paper so they could print out packets that needed to be sent with the residents when they go out of the facility. Staff have purchased soap, bodywash, lotion, laundry soap, bleach, bread, gas for the van, and incontinent briefs for the residents. Record review of invoices provided by the Human Resource Director indicated unpaid balances for the following: 1. Telephone and internet vendor invoice dated [DATE]- Past due balance of $16,985.35. The phone was disconnected on [DATE]. Internet was disconnected on [DATE]. 2. Energy vendor invoice dated [DATE] - Past due balance of $41,159.61 with a due date of [DATE]. 3. Water vendor invoice undated - Past due balance of $5292.92 with a due date of [DATE]. 4. Fire and Security vendor - Past due balance of $11,497.06 as of [DATE] - a total of 11 invoices dated [DATE] - [DATE]. Account was suspended on [DATE] and 10-day termination notice was to be given. 5. Ice machine vendor invoice dated [DATE]- Past due balance of $137.12 with a due date of [DATE] and ice machine to be picked up on [DATE] if not paid. 6. Milk vendor invoice dates from [DATE]-[DATE] (22 invoices)- Past due balance of $1,360.59. Delivery of milk stopped [DATE]. 7. Garbage and waste vendor invoice dated [DATE]- Past due balance of $1,141.08. Subject to service suspension and/or container removal. 9. Pharmacy Consultant invoice dated [DATE]- Past due balance (not disclosed on invoice). Pharmacy services to be terminated on [DATE]. 10. Insurance vendor for van undated- Policy cancelled effective date on [DATE] for non-payment. Amount unknown. In an interview on [DATE] at 11:15 am, [NAME] B said the facility had to substitute meals due to not having the required food for the menu. She said they attempt to make sure the residents were receiving the correct nutritional value. She said at times, the facility does not have milk, bread, coffee, artificial sweetener. [NAME] B said she had purchased ketchup, mustard, and artificial sweetener for the residents. In an interview on [DATE] at 11:30 am, the Maintenance Director stated he could not purchase supplies to fix things at the facility due to the facility having a past due balance at a local hardware store, approximately $7000. The facility had a past due balance with the vendor who serviced the dishwasher, washing machines and dryers and could not get maintenance services. He said the hot water heater for the laundry did not work and could not get it fixed. He stated that he purchased supplies out of his own pocket to fix things at the facility for the residents. He said the facility owed him $125 for supplies he recently purchased, and they have never paid him. In an interview on [DATE] at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on [DATE] and had never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on [DATE] so that the residents and their families could communicate with each other. She said the facility could not send or receive faxes. The staff had to use their personal cell phones to conduct facility business. In an interview on [DATE] at 02:10 PM, Housekeeper C stated there was no hot water in the laundry and all laundry was being washed in cold water. She said the washing machine had no chemicals and needed to be serviced. She said staff purchased bleach and laundry soap as the facility had not been purchasing those items due to not paying their bill. In an interview on [DATE] at 10:10 am, LVN D said that she bought out of her pocket soap, bodywash, lotion, ink, and paper for the printer. She said if she did not purchase these things the residents would go without. In an interview on [DATE] at 10:15 am, LVN E said that she purchased ink and paper for the printer. She said when a resident was sent out of the facility, they have to print a paper packet to go with them. She said due to the facility not having phone or fax services, she had to use her own cell phone to conduct facility business. She said the facility was unable to receive faxes from doctors and hospitals. She said the residents' families have expressed to her their frustration about not being able to contact the facility or their loved ones. In an interview on [DATE] at 10:50 am, the DON said she was aware the facility did not have hot water for the laundry. She said when a resident goes out of the facility, they had to print out a packet concerning the resident's information to be sent with them and the nurses had been buying the ink and paper for that. If they did not purchase the items, they would not be able to send out a packet the receiving facility was requesting. In an interview with DON on [DATE] at 10:00am and a record review of an e-mail dated [DATE] at 11:05 am from the Director of Nursing to the CEO, the DON requested Supplies and Payments: We are nearly out of essential supplies, including toilet paper. Could you confirm when the outstanding bills will be settled so that we can restock as needed? Petty Cash: Do we have an estimated timeline for the release of petty cash? Several team members have been using funds to address immediate building needs. Could you advise on the status of these items? The DON said the CEO never responded to the e-mail. In an interview on [DATE] at 10:45 am, the Dietary Manager stated the residents were budgeted $6 a day for breakfast, lunch, and dinner. She said that amount was not enough to purchase all the food items for the menus. As a result, the facility had to substitute items on the menu. An example for today at lunch, it called for hamburger meat but there wasn't enough money to purchase that, so it was substituted with another item on the menu that was chicken. She said she had purchased coffee, milk, artificial sweetener, and tea bags for the residents. In an interview on [DATE] at 11:00 am, the Laundry Supervisor stated there was no hot water for the laundry. The resident's laundry was being washed in cold water. She said the hot water heater had been out for over a month. She said the washing machine did not have the correct chemicals to sanitize the resident's laundry properly. She said the washing machine had an error code and needed to be serviced. She said the facility had not paid the bill to the servicer and they would not come to fix it. She said staff purchased bleach and laundry detergent as the facility did not provide laundry soap or bleach. She said she had purchased laundry supplies for the residents out of her own pocket. She stated it had been reported, and maintenance was aware. In an interview on [DATE] at 2:00 pm, the local Ombudsman reported it was difficult to contact the facility due to having no phone service. Individual facility staff had to be contacted. The ombudsman said she was made aware of the communication with the owner because staff had been forwarding emails from the owner and it is very demeaning, and negative. In an interview on [DATE] at 2:54 pm, the Maintenance Director stated the facility needed a new hot water heater for the laundry. He said the facility could not get anyone to come out and look at the hot water heater due to the facility owing everyone money. He said the washing machine could not be serviced due to an unpaid bill. He said the facility could not order the proper chemicals for the washing machine due to an unpaid bill. He said the CEO was aware. In an interview on [DATE] at 9:30 am, Resident #1's POA expressed her concern about the facility not having an Administrator in the building and questioned as if this was causing a delay of Resident #1 being placed on hospice care requested on [DATE]. In an interview on [DATE] at 11:23 am with the Activity Director, she stated she was purchasing blow-up calendars for the activity bulletin board out of her own pocket and the facility would reimburse her. She said she purchased a calendar for January and the facility did not reimburse her. She said the facility owed her $30. She said she purchased BINGO winnings for the residents such as coke, candy, and popcorn out of her own pocket. If she did not, the residents would not have any BINGO winnings. In an interview on [DATE] at 12:00 pm, Facility Physician A said she was aware the facility was not paying its bills. She said it makes communication very difficult as she could not send or receive faxes with the facility. She had to conduct business on staff's individual cell phones. In an interview on [DATE] at 1:35 pm, CNA F stated she had purchased soap and body wash for the residents so they could have a bath. In an interview with the CEO on [DATE] at 4:20 pm, he said don't worry about the utilities, they will not get shut off. I will not be able to keep up 30-day payments due to all the Medicaid in the facility and them not paying that much. He said he purchased the facility 6 months ago and it takes time to get everything switched over to a new account. He stated he was not going to pay any back service because he was not responsible for anything before he bought the facility. He said the facility staff had not communicated to him about the food or lack of food, and the best he could do was contact his purchase person. He said he was not aware the washing machine did not have hot water and needed to be serviced. CEO stated there was no Interim Administrator, and the position was posted on job website and no one licensed had applied. In an interview with the CEO on [DATE] at 4:55 pm, he stated he signed a new contract for the electric vendor. He said the water bill was only 2 months behind and that it was not late enough to be shut off so that was fine. He said the Fire and Security vendor were still within terms and would complete repairs. He said he would get payment sent out tomorrow for the ice machine vendor. He said they had a new pharmacy consultant to start [DATE]. In an interview with the Social Worker on [DATE] at 1:00 pm, she stated for the last 3 to 4 weeks, she had received calls from family members 2 to 3 times per week on her personal cell phone upset and worried due to the facility phone number not working. In an interview on [DATE] at 10:00 am, the Human Resource Director said the internet was disconnected on [DATE] in the afternoon for non-payment. The facility did not have any internet service from [DATE] to the morning of [DATE]. She stated the facility had insurance on the van and provided an invoice. In an interview on [DATE] at 11:25 am, the Activity Director said she was responsible for taking residents to doctor's appointments but had not taken them in February or March due to the van not having insurance or current tags. In an interview on [DATE] at 12:55 pm, the Dietary Manager said she had to substitute pot roast that was on the menu for chicken due to pot roast being over $200. She said she did not have enough money to purchase the required food items on the menu. In an interview on [DATE] at 1:00 pm, LVN D and LVN E stated due to the internet being down, the nurses were not able to access the computer for medication administration. They stated the residents on the Yellow [NAME] Hallway did not have TV service due to the internet being out and the facility did not purchase a hot spot for that hallway. They reported the residents did not have any coffee today and they were going to go purchase some. In an observation on [DATE] at 1:15 pm, the facility van's tag displayed on the front windshield expired on ,d+[DATE]. In an interview on [DATE] at 1:30 pm, the DON said due to the facility having no insurance on the van, 3 residents (Resident #2, Resident #9, and Resident #11) had missed their doctors' appointments. One resident missed a cardiology and nephrology appointment; two residents missed an appointment with their primary doctor and 2 residents have been taken to their appointments by their family. The DON said a potential negative outcome would be the residents would not receive the proper treatment they needed. In an interview on [DATE] at 10:16 am, this writer contacted the van insurance company from the invoice provided by the Human Resource Director and was informed the policy had been cancelled and was not active. In an interview on [DATE] at 10:45 am, the Dietician said she was concerned about the food budget and not enough money to cover the menu. She said she was not aware the facility had been substituting the menu as frequently as they were doing. She said the facility should not be having to substitute more than 2 meals a week. In an interview on [DATE] at 1:15 pm, the laundry supervisor said the facility was not using the recommended bleach or detergent for the laundry, and no alkaline is being used. One washing machine is not equipped anymore to receive chemicals and they wash items in that one that doesn't require bleach. She said it had been over 2 years since the washing machines had been serviced. She said as a result the laundry had the potential to not be sanitized properly. In an interview on [DATE] at 8:24 am, Physician B stated it was very difficult to communicate with the facility due to no phone or fax service. He said a resident had an appointment with him yesterday, but it was cancelled. He was not aware it was cancelled due to the facility not being able to transport residents due to having no insurance on the facility van. In an interview on [DATE] at 12:00 pm, Facility Physician A said she was not aware residents missed doctor's appointments. She said the resident that missed his cardiology and nephrology appointments were considered important appointments. She said the facility called her about Resident #2 that was having slight bleeding from her vaginal area; She said she asked the facility to bring the resident to her office, but was informed they could not due to no insurance on the van. She said as a result, she was going to go to the facility to evaluate her. In an interview and record review on [DATE] at 10:10 am, the DON provided documentation the van insurance policy was cancelled on [DATE]. She said on [DATE], Resident #3 sustained a fall. The family requested her to be sent to the ER. DON stated the family took her to the ER and left. The facility had to use the facility van to pick her up from the ER, although there was no insurance on the van. In an interview on [DATE] at 11:35 am, the DON said Resident #2 was being sent to the ER, via ambulance for a change in condition. She said Facility Physician A did not get to see her prior to being sent. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:52 pm. The DON and Human Resource Director were notified. The DON was provided with the IJ template on [DATE] at 3:52 pm. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 12:47 pm and included: The facility needs to take immediate action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. Plan of Removal 1). Action: The Chief Executive Officer (CEO) and Managing Partner re-educated the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility; emphasis was stressed on the importance of providing oversight of facility care and services in accordance with professional standards of practice and principles, to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. The mode of education was in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administrative Management (Governing Board). The teach-back method was used to assess comprehension. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Managing Partner 2). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet to review and make payments or payment arrangements for: 1. Telephone and internet vendor on [DATE], $10,000.00 was paid, the remaining payment was made on [DATE] in the amount of $7987.28, the amount told to us from the company to activate service.; 2. Insurance vendor for the facility van has been paid in the amount of $141.99 on [DATE]. 3. Registration tags for the facility van was paid on 3.17.25 in the amount of $74.00 to County Tax Office. 4. Fire and security vendor - have confirmed that we are not on hold and have sent an email confirming so on 3.14.25. If the internet is out, the emergency plan to ensure the staff have access to MARs and TARs will be to use the Hot spots for internet. Until Telephone and internet have been restored, while these are out, the facility will continue to use mobile phone and internet Hot Spots to communicate and document as required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. If the hot spots are not working, the DON was educated on the need to obtain paper-printed MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available and printing abilities are not available locally. The facility Social Worker will call each family to share the mobile phone number if/when needed. The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed to communicate to people outside the facility. The facility's Human Resource Director will contact the facility's vendors to share the phone number if/when required. To prevent future service interruptions, the Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet monthly to review the facility's outstanding invoices and ensure vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO) 3). Action: The Director of Nursing (DON) will complete a Medication Error Form for each of the identified 11 residents in which medication were given at a different time or omission occurred; the form includes communicating with the medical provider, the responsible party, facility management and pharmacist consultant, in addition to type of error and reason for error (Examples of medications errors include: a. Omission - a drug is ordered but not administered; b. Unauthorized drug - a drug is administered without a physician's order; c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given); d. Wrong route of administration (e.g., ear drops given in eye); e. Wrong dosage form (e.g., liquid ordered, capsule given); f. Wrong drug (e.g., vibramycin ordered, vancomycin given); g. Wrong time; and the corrective action taken and measures to prevent similar error(s) recurrence. The Director of Nursing reviewed the other resident's Medication Administration Records (MARs) and did not reveal further discrepancies or errors. The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) 4). Action: The Director of Nursing (DON) will re-educate nurses (RN/s/LVNs) and certified medication aides (CMAs) on the facility's policies: Administering Medications and Medication Errors - the different types and immediate actions to take to prevent adverse consequences. The mode of education will be in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administering Medications and Adverse Consequences and Medications Errors. The teach-back method was used to assess comprehension. To evaluate further understanding, the Director of Nursing will complete a weekly Medication Pass Observation to each nurse and medication aide for the next 4 weeks and quarterly thereafter. Education is done as well regarding obtaining MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available. Facility will have the hotspots that were purchased available to use if the main internet is to stop working until pharmacy deliver paper MARS and TARs. In the absence of the DON, the Chief Nursing Officer (CNO) will request paper-printed MARs and TARs from the pharmacy vendor. Start Date: [DATE]. Completion Date: [DATE] Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) 5). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will post the facility's administrator's vacant position and continue active recruitment to fill the facility administrator's vacant position. With a sign on bonus posted on 3.15.25. Until the position is filled, all items needed for resident care are to be communicated to the facility's Director of Nursing (DON), as for ancillary services, such as dietary and environmental services, are to be communicated to the facility's Human Resource Director, Both - DON and HR Director will participate in a conference call with the Chief Executive Officer (CEO) and Chief Operating Officer (COO) weekly on Thursdays at 11 am that arrangements can be made to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. This conference call will continue weekly with the new administrator once onboarded and the weekly minutes reviewed monthly during the facility's monthly QAPI to determine if changes in needed supplies, their quantity and/or delivery dates are required in order to be altered to ensure timely ordering and delivery. Items to be reviewed weekly will include food needed for the menu, milk, coffee, tea, artificial sweetener, hot chocolate, snacks, condiments, soap, shampoo, conditioner, lotion, laundry soap, bleach, ink for printers, paper for printers, chemicals for laundry, and gas for the van, along with routine service needs/requests for the dishwasher, washing machine, and dryer. Staff will be educated on 3.17.25 by HR that when a facility or resident need related to supplies and vendor payments to communicate with HR who will review supply and ensure supply is replenished before the item runs out. Laundry staff were educated by HR that when chemical supply becomes low to notify HR who will ensure supply is replenished prior to running out. Maintenance director will be educated on 3.17.25 to monitor once a week the supply visually and discuss with staff on site the supply level to see if additional chemicals need to be ordered and will communicate to HR. Department heads will be educated on 3.17.25 by HR that each department head will monitor its supplies once a week and communicate to HR any items needed. Maintenance director will do housekeeping and laundry, DON will do nursing, HR will do office supplies. Start Date: [DATE]. Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA) 6). Action: Staff will be reimbursed for their out-of-pocket expenses per usual procedures, including submitting reimbursement requests and receipts. The Human Resource Director (HR) will instruct line staff not to purchase items for the facility in the absence of the facility administrator; all purchases will be made by the facility administrator and/or the HR Director after the weekly Thursday conference call. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA) 7). Action: Annual van registration and insurance will be added to the annual maintenance checklist to ensure timely registration renewal; The facility administrator will review the yearly checklist during QAPI to ensure timely review. Start Date: [DATE] Completion Date: [DATE] Responsible: Maintenance Director and Facility Administrator 8). Action: An ad-hoc QAPI meeting will be held, and the facility Medical Director will be notified of the deficient practice and the approved removal plan. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA). Verification: Record review of receipt payment dated [DATE] to Water Department dated [DATE] for $1,579.21. Record review of receipt payment dated [DATE] reflected $1,141.08 to garbage and waste. Record review of receipt payment dated [DATE] to Water Department for $1,579.21 Record review of receipt dated [DATE] reflected $286.86 for ice machine payment. Observation on [DATE] at 3:46 pm revealed the fire sprinkler system with tag noted to have been serviced and working. In an Interview on [DATE] at 11:20am, Resident #1 stated she gets all of her medications as far as she knows and had no concerns. She stated she has her own cell phone so not affected. In an Interview on [DATE] at 11:22am, Resident #9 stated he gets all of his medications and has no concerns with care. In an observation on [DATE] at 11:55am, 9 residents were in the dining room. The menu was followed, and no food concerns were noted. In an observation on [DATE] at 9:20am, the kitchen had 7 days of non-perishable food and 3 days of perishable and no concerns were noted. In an Interview on [DATE] at 3:17pm, Resident # 11 stated she has access to her visitors and them to her and no concerns of anything about her care at the facility. In an Interview on [DATE] at 3:27pm, Resident #13 and Resident #10 stated they have access to their visitors and have no issues or concerns with their care and get their doctor appointments. A record review of the in-service titled Governing Responsibility dated [DATE] and signed by the CEO and COO reflected the importance of paying bills timely and the expectation of them to meet weekly on Thursdays to ensure bills are paid timely. Observation on [DATE] at 12:23pm revealed 9 residents in the dining room with no portion concerns. Food appears palatable and displayed well. Record review of the maintenance checklist on [DATE] at 3:15 pm revealed vehicle registration and insurance renewal was added annually with a next review date of [DATE]th, 2025. Record review of Medication Pass Observations for 5 nurses dated [DATE]-[DATE] for med pass observation by DON reflected medication pass observations were completed by the DON of her nurses. In an interview on [DATE] at 12:16 pm, the COO confirmed she had been in-serviced concerning bills must be paid in a timely manner and she is to meet weekly with the CEO and Human Resource Director weekly to review. In an interview on [DATE] at 1:27 pm, LVN E stated she had received 1:1 instruction from the DON on how to administer medications during an internet outage and how to obtain a copy of the paper MAR if one is not available. She said she had completed 2 in-services regarding medication administration and medication errors. In an interview and record review on [DATE] at 1:59 pm, the Human Resource Director stated she purchased additional data for the hot spots early today and provided a copy of the receipt dated [DATE] that indicated additional data purchased. The Human Resource Director provided the training sheet that was completed with the department heads on the process of communicating supply needs to be completed weekly. Human Resource Director said that 1:1 training with the department heads had been completed and they reviewed the process of communication for supply needs. She said she is to have a meeting weekly, on Thursdays, with the CEO and COO concerning supply needs of the facility. In an interview on [DATE] at 2:13 pm, the Human Resource Director confirmed weekly meetings were to be held with the CEO and COO on Thursdays to discuss billing and concerns. Record review/Observation on [DATE] at 2:45 pm of job website revealed the Administrator's position was posted for a salary up to $50,[AGE] yearly with a sign on bonus. In an interview on [DATE] at 3:37 pm, the Maintenance Director stated he was given the task of monitoring supplies for the laundry weekly. He created a spread sheet weekly for the laundry staff to review needed supplies. Maintenance Director said he had the vehicle insurance and registration task added to his annual checklist. In an interview on [DATE] at 4:00 pm, the DON reported all the resident's representatives had been contacted regarding the temporary phone number for the facility and documented in the electronic record. The task was completed by the nurses as the Social Worker was not available. The DON said she was given the weekly responsib [TRUNCATED]

Based on interview and record review the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and reports to the governing body, in that: The facility had not had an administrator since [DATE]. The governing body failed to provide the facility with enough money to keep up services including telephone service, internet service, food services, van registration/insurance, laundry services, and fire and security services. An Immediate Jeopardy was identified on [DATE] at 3:52 pm. The IJ template was provided to the facility on [DATE] at 3:52pm. While the Immediate Jeopardy was removed on [DATE] at 4:36 pm, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could place residents at risk of decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care. The findings included: During an interview on [DATE] at 9:30 am, the DON said the facility had not had an Administrator since [DATE]. She said the only administrative staff at the facility were the DON and Human Resource Director. She said the facility had not been paying vendors. The phones/fax were not working. The staff had to utilize their own cell phones to conduct facility business. The facility is not able to send or receive faxes. A staff member bought a pre-paid cell phone, so the residents were able to call their family and vice versa. The staff went and bought milk, coffee, and hot chocolate for the residents, yesterday [DATE], due to the facility not having any for the residents. The ice machine was rented and was scheduled for repossession next Wednesday, [DATE] for non-payment. The nurses had purchased ink cartridges and paper so they can print out packets that need to be sent with the residents when they go out of the facility. Staff had purchased soap, bodywash, lotion, laundry soap, bleach, bread, gas for the van, and incontinent briefs for the residents. Record review of invoices provided by the Human Resource Director indicated unpaid balances for the following: 1. Telephone and internet vendor invoice dated [DATE]- Past due balance of $16,985.35. The phone was disconnected on [DATE]. Internet was disconnected on [DATE]. 2. Energy vendor invoice dated [DATE] - Past due balance of $41,159.61 with a due date of [DATE]. 3. Water vendor invoice undated - Past due balance of $5292.92 with a due date of [DATE]. 4. Fire and Security vendor - Past due balance of $11,497.06 as of [DATE] - a total of 11 invoices dated [DATE] - [DATE]. Account was suspended on [DATE] and 10-day termination notice was to be given. 5. Ice machine vendor invoice dated [DATE]- Past due balance of $137.12 with a due date of [DATE] and ice machine to be picked up on [DATE] if not paid. 6. Milk vendor invoice dates from [DATE]-[DATE] (22 invoices)- Past due balance of $1,360.59. Delivery of milk stopped [DATE]. 7. Garbage and waste vendor invoice dated [DATE]- Past due balance of $1,141.08. Subject to service suspension and/or container removal. 9. Pharmacy Consultant invoice dated [DATE]- Past due balance (not disclosed on invoice). Pharmacy services to be terminated on [DATE]. 10. Insurance vendor for van undated- Policy cancelled effective date on [DATE] for non-payment. Amount unknown. In an interview on [DATE] at 11:15 am, [NAME] B said the facility had to substitute meals due to not having the required food for the menu. She said they attempt to make sure the residents received the correct nutritional value. She said at times, the facility did not have milk, bread, coffee, artificial sweetener. She said she had purchased ketchup, mustard, and artificial sweetener for the residents. In an interview on [DATE] at 11:30 am, the Maintenance Director stated he could not purchase supplies to fix things at the facility due to the facility having a past due balance at a local hardware store, approximately $7000. The facility had a past due balance with the vendor who services the dishwasher, washing machines and dryers and could not get maintenance services. He said the hot water heater for the laundry did not work and could not get it fixed. He stated that he purchased supplies out of his own pocket to fix things at the facility for the residents. He said the facility currently owed him $125 for supplies he recently purchased, and they have never paid him. In an interview on [DATE] at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on [DATE] and had never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on [DATE] so that the residents and their families could communicate with each other. She said the facility could not send or receive faxes. The staff were having to use their personal cell phones to conduct facility business. She said there was no acting interim and that her and the DON were covering. In an interview on [DATE] at 02:10 PM, Housekeeper C stated there was no hot water in the laundry and all laundry was being washed in cold water. She said the washing machine had no chemicals and needed to be serviced. She said staff had purchased bleach and laundry soap as the facility had not been purchasing those items due to not paying their bill. In an interview on [DATE] at 10:10 am, LVN D said that she bought out of her pocket soap, bodywash, lotion, ink, and paper for the printer. She said if she did not purchase these things the residents would go without. In an interview on [DATE] at 10:15 am, LVN E said that she purchased ink and paper for the printer. She said when a resident was sent out of the facility, they had to print a paper packet to go with them. She said due to the facility not having phone or fax services, she had to use her own cell phone to conduct facility business. She said the facility was unable to receive faxes from doctors and hospitals. She said the residents' families had expressed to her their frustration about not being able to contact the facility or their loved ones. In an interview on [DATE] at 10:50 am, the DON said she was aware the facility did not have hot water for the laundry. She said when a resident goes out of the facility, they had to print out a packet concerning the resident's information to be sent with them and the nurses had been buying the ink and paper for that. If they did not purchase the items, they would not be able to send out a packet the receiving facility was requesting. In an interview with the DON on [DATE] at 10:00 am and a record review of an e-mail dated [DATE] at 11:05 am from the Director of Nursing to the CEO, the DON requested Supplies and Payments: We are nearly out of essential supplies, including toilet paper. Could you confirm when the outstanding bills will be settled so that we can restock as needed? Petty Cash: Do we have an estimated timeline for the release of petty cash? Several team members have been using funds to address immediate building needs. Could you advise on the status of these items? The DON said the CEO never responded to the e-mail. In an interview on [DATE] at 10:45 am, the Dietary Manager stated the residents were budgeted $6 a day for breakfast, lunch, and dinner. She said that amount was not enough to purchase all the food items for the menus. As a result, the facility had to substitute items on the menu. An example for today at lunch, it called for hamburger meat but there wasn't enough money to purchase that, so it was substituted with another item on the menu that was chicken. She said she had purchased coffee, milk, artificial sweetener, and tea bags for the residents. In an interview on [DATE] at 11:00 am, the Laundry Supervisor stated there was no hot water for the laundry. The resident's laundry was being washed in cold water. She said the hot water heater had been out for over a month. She said the washing machine did not have the correct chemicals to sanitize the resident's laundry properly. She said the washing machine had an error code and needed to be serviced. She said the facility had not paid the bill to the servicer and they would not come to fix it. She said staff purchased bleach and laundry detergent as the facility did not provide laundry soap or bleach. She said she had purchased laundry supplies for the residents out of her own pocket. She stated it had been reported, and maintenance was aware. In an interview on [DATE] at 2:00 pm, the local Ombudsman reported it was difficult to contact the facility due to having no phone service. Individual facility staff had to be contacted. The ombudsman stated the facility staff had forwarded emails from the CEO and she stated they appeared demeaning and negative, but no specifics were provided. In an interview on [DATE] at 2:54 pm, the Maintenance Director stated the facility needed a new hot water heater for the laundry. He said the facility could not get anyone to come out and look at the hot water heater due to the facility owing everyone money. He said the washing machine could not be serviced due to an unpaid bill. He said the facility could not order the proper chemicals for the washing machine due to an unpaid bill. He said the CEO was aware. In an interview on [DATE] at 9:30 am, Resident #1's POA expressed her concern about the facility not having an Administrator in the building and questioned as if this caused a delay of Resident #1 being placed on hospice care requested on [DATE]. In an interview with the Activity Director, on [DATE] at 11:23 am, stated she had purchased blow-up calendars for the activity bulletin board out of her own pocket and the facility would reimburse her. She said she purchased a calendar for January and the facility would not reimburse her. She said the facility owed her $30. She said she purchased BINGO winnings for the residents such as coke, candy, and popcorn out of her own pocket. If she did not, the residents would not have any BINGO winnings. In an interview on [DATE] at 12:00 pm, Facility Physician A said she was aware the facility was not paying its bills. She said it made communication very difficult as she could not send or receive faxes from the facility. She had to conduct business on staff's individual cell phones. In an interview on [DATE] at 1:35 pm, CNA F stated she had purchased soap and body wash for the residents so they could have a bath. In an interview with the CEO on [DATE] at 4:20 pm, he said don't worry about the utilities, they will not get shut off. I will not be able to keep up 30-day payments due to all the Medicaid in the facility and them not paying that much. He said he purchased the facility 6 months ago and it takes time to get everything switched over to a new account. He stated he was not going to pay any back service because he was not responsible for anything before, he bought the facility. He said the facility staff had not communicated to him about the food or lack of food, the best he can do is contact his purchase person. He said he was not aware the washing machine did not have hot water and needed to be serviced. The CEO said the Administrator job was posted on a job website. He said no one that had a license has applied. He said there was no interim administrator at the facility. He said the DON and Human Resource Director were running the facility. In an interview with the CEO on [DATE] at 4:55 pm, he stated he signed a new contract for electric vendor. He said the water bill was only 2 months behind and that it is not late enough to be shut off so that was fine. He said the Fire and Security vendor were still within terms and would complete repairs. He said he would get payment sent out tomorrow for the ice machine vendor. He said they had a new pharmacy consultant to start [DATE]. In an interview with the Social Worker on [DATE] at 1:00 pm, she stated for the last 3 to 4 weeks, she had received calls from family members 2 to 3 times per week on her personal cell phone upset and worried due to the facility phone number not working. In an interview on [DATE] at 12:30 pm, the DON said possible negative outcomes of not having an Administrator was the facility was not being run effectively, making sure there were supplies in the building, and QAPI was not being done. In an interview on [DATE] at 10:00 am, the Human Resource Director said the internet was disconnected on [DATE] in the afternoon for non-payment. The facility did not have any internet service from [DATE] to the morning of [DATE]. She stated the facility had insurance on the van and provided an invoice. In an interview on [DATE] at 11:25 am, the Activity Director said she was responsible for taking residents to doctor's appointments but had not taken them in February or March due to the van not having insurance or current tags. In an interview on [DATE] at 12:55 pm, the Dietary Manager said she had to substitute pot roast that was on the menu for chicken due to post roast being over $200. She said she did not have enough money to purchase the required food items on the menu. In an interview on [DATE] at 1:00 pm, LVN D and LVN E stated due to the internet being down, the nurses were not able to access the computer for medication administration. They stated the residents on the Yellow [NAME] Hallway did not have TV service due to the internet being out and the facility did not purchase a hot spot for that hallway. They reported the residents did not have any coffee today and they were going to go purchase some. In an observation on [DATE] at 1:15 pm, the facility van's tag displayed on the front windshield expired on ,d+[DATE]. In an interview on [DATE] at 1:30 pm, the DON said due to the facility having no insurance on the van, 3 residents had missed their doctors' appointments. One resident missed a cardiology and nephrology appointment; 2 residents missed an appointment with their primary doctor and 2 residents have been taken to their appointments by their family. The DON said a potential negative outcome would be the residents would not receive the proper treatment they needed. In an interview on [DATE] at 10:16 am, this writer contacted the van insurance company from the invoice provided by the Human Resource Director and was informed the policy had been cancelled and was not active. In an interview on [DATE] at 10:45 am, the Dietician said she was concerned about the food budget and not enough money to cover the menu. She said she was not aware the facility had been substituting the menu as frequently as they were doing. She said the facility should not be having to substitute more than 2 meals a week. In an interview on [DATE] at 1:15 pm, the laundry supervisor said the facility was not using the recommended bleach or detergent for the laundry, and no alkaline was being used. One washing machine was not equipped anymore to receive chemicals and they wash items in that one that doesn't require bleach. She said it had been over 2 years since the washing machines had been serviced. She said as a result the laundry had the potential to not be sanitized properly. In an interview on [DATE] at 8:24 am, Facility Physician B stated it was very difficult to communicate with the facility due to no phone or fax service. He said a resident had an appointment with him yesterday, but it was cancelled. He was not aware it was cancelled due to the facility not being able to transport residents due to having no insurance on the facility van. In an interview on [DATE] at 12:00 pm, Facility Physician A said she was not aware residents missed doctor's appointments. She said the resident that missed his cardiology and nephrology appointments, those appointments would be considered important. She said the facility called her about Resident #2 that was having slight bleeding from her vaginal area: She said she asked the facility to bring the resident to her office, but was informed they could not due to no insurance on the van. She said as a result, she was going to go to the facility to evaluate her. In an interview and record review on [DATE] at 10:10 am, the DON provided documentation the van insurance policy was cancelled on [DATE]. She said on [DATE], Resident #3 sustained a fall. The family requested her to be sent to the ER. Stated the family took her to the ER and left. The facility had to use the facility van to pick her up from the ER, although there was no insurance on the van. In an interview on [DATE] at 11:35 am, the DON said Resident #2 was being sent to the ER, via ambulance for a change in condition. She said Facility Physician #1 did not get to see her prior to being sent. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:52 pm. The DON and Human Resource Director were notified. The DON was provided with the IJ template on [DATE] at 3:52 pm. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 12:47 pm and included: The facility needs to take immediate action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. Plan of Removal 1). Action: The Chief Executive Officer (CEO) and Managing Partner re-educated the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility; emphasis was stressed on the importance of providing oversight of facility care and services in accordance with professional standards of practice and principles, to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. The mode of education was in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administrative Management (Governing Board). The teach-back method was used to assess comprehension. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Managing Partner 2). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet to review and make payments or payment arrangements for: 1. Telephone and internet vendor on [DATE], $10,000.00 was paid, the remaining payment was made on [DATE] in the amount of $7987.28, the amount told to us from the company to activate service.; 2. Insurance vendor for the facility van has been paid in the amount of $141.99 on [DATE]. 3. Registration tags for the facility van was paid on 3.17.25 in the amount of $74.00 to County Tax Office. 4. Fire and security vendor - have confirmed that we are not on hold and have sent an email confirming so on 3.14.25. If the internet is out, the emergency plan to ensure the staff have access to MARs and TARs will be to use the Hot spots for internet. Until Telephone and internet have been restored, while these are out, the facility will continue to use mobile phone and internet Hot Spots to communicate and document as required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. If the hot spots are not working, the DON was educated on the need to obtain paper-printed MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available and printing abilities are not available locally. The facility Social Worker will call each family to share the mobile phone number if/when needed. The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed to communicate to people outside the facility. The facility's Human Resource Director will contact the facility's vendors to share the phone number if/when required. To prevent future service interruptions, the Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet monthly to review the facility's outstanding invoices and ensure vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO) 3). Action: The Director of Nursing (DON) will complete a Medication Error Form for each of the identified 11 residents in which medication were given at a different time or omission occurred; the form includes communicating with the medical provider, the responsible party, facility management and pharmacist consultant, in addition to type of error and reason for error (Examples of medications errors include: a. Omission - a drug is ordered but not administered; b. Unauthorized drug - a drug is administered without a physician's order; c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given); d. Wrong route of administration (e.g., ear drops given in eye); e. Wrong dosage form (e.g., liquid ordered, capsule given); f. Wrong drug (e.g., vibramycin ordered, vancomycin given); g. Wrong time; and the corrective action taken and measures to prevent similar error(s) recurrence. The Director of Nursing reviewed the other resident's Medication Administration Records (MARs) and did not reveal further discrepancies or errors. The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms. Start Date: [DATE] Completion Date: [DATE] Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) 4). Action: The Director of Nursing (DON) will re-educate nurses (RN/s/LVNs) and certified medication aides (CMAs) on the facility's policies: Administering Medications and Medication Errors - the different types and immediate actions to take to prevent adverse consequences. The mode of education will be in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administering Medications and Adverse Consequences and Medications Errors. The teach-back method was used to assess comprehension. To evaluate further understanding, the Director of Nursing will complete a weekly Medication Pass Observation to each nurse and medication aide for the next 4 weeks and quarterly thereafter. Education is done as well regarding obtaining MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available. Facility will have the hotspots that were purchased available to use if the main internet is to stop working until pharmacy deliver paper MARS and TARs. In the absence of the DON, the Chief Nursing Officer (CNO) will request paper-printed MARs and TARs from the pharmacy vendor. Start Date: [DATE]. Completion Date: [DATE] Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) 5). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will post the facility's administrator's vacant position and continue active recruitment to fill the facility administrator's vacant position. With a sign on bonus posted on 3.15.25. Until the position is filled, all items needed for resident care are to be communicated to the facility's Director of Nursing (DON), as for ancillary services, such as dietary and environmental services, are to be communicated to the facility's Human Resource Director, Both - DON and HR Director will participate in a conference call with the Chief Executive Officer (CEO) and Chief Operating Officer (COO) weekly on Thursdays at 11 am that arrangements can be made to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. This conference call will continue weekly with the new administrator once onboarded and the weekly minutes reviewed monthly during the facility's monthly QAPI to determine if changes in needed supplies, their quantity and/or delivery dates are required in order to be altered to ensure timely ordering and delivery. Items to be reviewed weekly will include food needed for the menu, milk, coffee, tea, artificial sweetener, hot chocolate, snacks, condiments, soap, shampoo, conditioner, lotion, laundry soap, bleach, ink for printers, paper for printers, chemicals for laundry, and gas for the van, along with routine service needs/requests for the dishwasher, washing machine, and dryer. Staff will be educated on 3.17.25 by HR that when a facility or resident need related to supplies and vendor payments to communicate with HR who will review supply and ensure supply is replenished before the item runs out. Laundry staff were educated by HR that when chemical supply becomes low to notify HR who will ensure supply is replenished prior to running out. Maintenance director will be educated on 3.17.25 to monitor once a week the supply visually and discuss with staff on site the supply level to see if additional chemicals need to be ordered and will communicate to HR. Department heads will be educated on 3.17.25 by HR that each department head will monitor its supplies once a week and communicate to HR any items needed. Maintenance director will do housekeeping and laundry, DON will do nursing, HR will do office supplies. Start Date: [DATE]. Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA) 6). Action: Staff will be reimbursed for their out-of-pocket expenses per usual procedures, including submitting reimbursement requests and receipts. The Human Resource Director (HR) will instruct line staff not to purchase items for the facility in the absence of the facility administrator; all purchases will be made by the facility administrator and/or the HR Director after the weekly Thursday conference call. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA) 7). Action: Annual van registration and insurance will be added to the annual maintenance checklist to ensure timely registration renewal; The facility administrator will review the yearly checklist during QAPI to ensure timely review. Start Date: [DATE] Completion Date: [DATE] Responsible: Maintenance Director and Facility Administrator 8). Action: An ad-hoc QAPI meeting will be held, and the facility Medical Director will be notified of the deficient practice and the approved removal plan. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. Start Date: [DATE] Completion Date: [DATE] Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA). Verification: Record review of receipt payment dated [DATE] to Water Department dated [DATE] for $1,579.21. Record review of receipt payment dated [DATE] reflected $1,141.08 to garbage and waste. Record review of receipt payment dated [DATE] to Water Department for $1,579.21 Record review of receipt dated [DATE] reflected $286.86 for ice machine payment. Observation on [DATE] at 3:46 pm revealed the fire sprinkler system with tag noted to have been serviced and working. In an Interview on [DATE] at 11:20am, Resident #1 stated she gets all of her medications as far as she knows and had no concerns. She stated she has her own cell phone so not affected. In an Interview on [DATE] at 11:22am, Resident #9 stated he gets all of his medications and has no concerns with care. In an observation on [DATE] at 11:55am, 9 residents were in the dining room. The menu was followed, and no food concerns were noted. In an observation on [DATE] at 9:20am, the kitchen had 7 days of non-perishable food and 3 days of perishable and no concerns were noted. In an Interview on [DATE] at 3:17pm, Resident # 11 stated she has access to her visitors and them to her and no concerns of anything about her care at the facility. In an Interview on [DATE] at 3:27pm, Resident #13 and Resident #10 stated they have access to their visitors and have no issues or concerns with their care and get their doctor appointments. A record review of the in-service titled Governing Responsibility dated [DATE] and signed by the CEO and COO reflected the importance of paying bills timely and the expectation of them to meet weekly on Thursdays to ensure bills are paid timely. Observation on [DATE] at 12:23pm revealed 9 residents in the dining room with no portion concerns. Food appears palatable and displayed well. Record review of the maintenance checklist on [DATE] at 3:15 pm revealed vehicle registration and insurance renewal was added annually with a next review date of [DATE]th, 2025. Record review of Medication Pass Observations for 5 nurses dated [DATE]-[DATE] for med pass observation by DON reflected medication pass observations were completed by the DON of her nurses. In an interview on [DATE] at 12:16 pm, the COO confirmed she had been in-serviced concerning bills must be paid in a timely manner and she is to meet weekly with the CEO and Human Resource Director weekly to review. In an interview on [DATE] at 1:27 pm, LVN E stated she had received 1:1 instruction from the DON on how to administer medications during an internet outage and how to obtain a copy of the paper MAR if one is not available. She said she had completed 2 in-services regarding medication administration and medication errors. In an interview and record review on [DATE] at 1:59 pm, the Human Resource Director stated she purchased additional data for the hot spots early today and provided a copy of the receipt dated [DATE] that indicated additional data purchased. The Human Resource Director provided the training sheet that was completed with the department heads on the process of communicating supply needs to be completed weekly. Human Resource Director said that 1:1 training with the department heads had been completed and they reviewed the process of communication for supply needs. She said she is to have a meeting weekly, on Thursdays, with the CEO and COO concerning supply needs of the facility. In an interview on [DATE] at 2:13 pm, the Human Resource Director confirmed weekly meetings were to be held with the CEO and COO on Thursdays to discuss billing and concerns. Record review/Observation on [DATE] at 2:45 pm of job website revealed the Administrator's position was posted for a salary up to $50,[AGE] yearly with a sign on bonus. In an interview on [DATE] at 3:37 pm, the Maintenance Director stated he was given the task of monitoring supplies for the laundry weekly. He created a spread sheet weekly for the laundry staff to review needed supplies. Maintenance Director said he had the vehicle insurance and registration task added to his annual checklist. In an interview on [DATE] at 4:00 pm, the DON reported all the resident's representatives had been [TRUNCATED]

Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possiblefor 1 of 1 washing machines observed for infection control practices. The facility failed to make sure the washing machine had hot water and chemicals to sanitize and clean linens and clothing for residents. This failure could affect the residents in the facility by placing them at risk of possible unsanitary conditions and run the risk of infections. Findings included: In an interview on 02/22/25 at 11:30 pm, the Maintenance Director stated the hot water heater for the laundry did not work and was not able to get it fixed due to the facility owing money to the vendor. The washing machine had an error code, and it needed to be serviced but could not get it serviced due to the past bill . The washing machines did not have the correct chemicals but cannot order them due to a past bill. In an interview on 02/22/25 at 02:10 PM, Housekeeper C stated there was no hot water in the laundry and all laundry was being washed in cold water. She said the washing machine had no chemicals and needed to be serviced. She said staff have purchased bleach and laundry detergent so they could do the resident's laundry, but they were not the required chemicals. She said the laundry had a smell of urine after being washed. In an interview on 02/23/25 at 10:50 am, the DON said she was aware the facility did not have hot water for the laundry. The DON said there have been no reports of residents having skin issues or infections relating to the laundry. The DON was aware staff were purchasing laundry soap and bleach for the washing machine for the the resident's laundry. In an observation on 02/23/25 at 12:23 pm, the linen closet was observed. The linens were stained with dark spots and had a musty odor. The pads smell of urine. In an interview and observation on 02/24/25 at 11:00 am, the Laundry Supervisor stated the facility did not have hot water for the laundry for approximately over a month due to the hot water heater not working. The resident's laundry was being washed in cold water. The laundry supervisor also stated it had been reported to maintenance, and maintenance was aware. She said the washing machine did not have the correct chemicals to sanitize the resident's laundry properly. She said the washing machine had an error code and it needed to be serviced. She said the facility had not paid the bill to the servicer and will not come to fix it. She said staff purchased bleach and laundry soap as the facility had not been providing them. She said the linens smell of urine, especially the pads. Observed and smelled the clean linens, the pads had an odor of urine. In an interview on 02/24/25 at 2:54 pm, the Maintenance Director stated the facility needed a new hot water heater for the laundry. He said the facility could not get anyone to come out and look at the hot water heater due to the facility owing everyone money. He said the washing machine could not be serviced due to an unpaid bill. He said the facility could not order the proper chemicals for the washing machine due to an unpaid bill. He said that it had been reported to corporate and they were aware of the situation but failed to get it fixed/serviced. In an interview with the CEO on 02/25/25 at 4:20 pm, he said he was not aware the washing machine did not have hot water and needed to be serviced. Review of the facility's Resident List Report, dated 02/22/25, revealed a census of 23 residents.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 7 (Resident #1) residents reviewed for resident rights. The facility failed to provide Resident #1 hospice care per resident's request. This failure placed residents at risk of their rights to make choices about their life being disregarded. Findings include: Record Review of Resident #1 Admission Record dated 02/22/25 revealed Resident #1 was an [AGE] year-old female with an original admitted [DATE] with the latest return date of 02/06/25. Resident had a diagnosis of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. Record review of Resident #1's Admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 13 (cognitively intact). Her pain assessment was negative for the 5-day look back period. Record review of Resident #1's Care Plan on 02/16/25 revealed a care plan for pain related to multiple myeloma, osteoarthritis, and skin blisters. Record review of Resident #1 electronic record revealed the Resident #1 requested hospice services on 02/16/25 due to uncontrolled pain. The facility physician wrote an order for hospice services on 02/16/25 and an order for Tylenol 3 every 4 hours as needed for pain. A progress note dated 02/16/25, by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. Record review of Resident #1's pain levels revealed on 02/16/25, Resident #1 started experiencing pain at a pain level of 8 and constantly stayed at a high level since that time with intermittent reduction related to pain medication administration. Record review of Resident #1's Medication Administration Record for February 2025, revealed she was prescribed: Acetaminophen-Codeine Oral Tablet 300-30mg at bedtime for Poly osteoarthritis and Multiple Myeloma in relapse with an order date of 02/16/25 and Acetaminophen-Codeine Oral Tablet 300-30mg every 4 hours as needed for pain with an order date of 02/16/25. In an interview during the entrance conference on 03/07/25 at 9:30 am, LVN A stated Resident #1 has requested hospice services on 02/16/25 but the CEO had not approved the services. She said Resident #1 was in pain, the Facility Physician has ordered pain medication, but it only helped some. In an interview and observation with Resident #1 on 02/23/25 at 12:30 pm, the resident was sitting up in her recliner very still and stiff and did not move any part of her body throughout the conversation. She expressed that she was in a lot of pain , especially in her right shoulder. She rated her pain at an 8 on a scale of 1-10 and said her pain never gets below a 6. She said she received pain medications, but they only help a little and just takes the edge off. She said she would like hospice services to help with pain. She said she requested hospice services but did not know the status of hospice care. In an interview with the DON on 02/24/25 at 10:50 am, she said the CEO had to approve hospice services before they could proceed with getting the resident hospice care. She said she emailed the owner of the facility on 02/17/25 requesting hospice services for Resident #1. The DON provided documentation of the email. Stated the Owner never responded to the e-mail. In a record review of an e-mail dated 02/17/25 at 11:05 am from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please being the process to set this up? In an interview on 02/25/25 at 9:30 am with Resident #1 's POA, she said Resident #1 expressed to her on 02/16/25 that she wanted hospice services due to pain. She said she talked to Resident #1 daily on the phone and Resident #1 had expressed to her that she had been a lot of pain daily. She said she was told by the facility that corporate had to approve hospice care before hospice services could be obtained and are waiting on that to happen. She said she was upset due to the long time it was taking to get Resident #1 on hospice services to help with her pain. In an interview with the DON on 02/25/25 at 10:00 am, she said she went ahead and contacted hospice services for Resident #1 without the permission of the CEO due to the resident being in pain. In an interview with the facility physician on 02/25/25 at 12:00 pm, she said the facility contacted her on 02/16/24 that Resident #1 was requesting hospice services per patient request and that she was in pain. She said she wrote an order for hospice services on 02/16/24 and an order to increase her pain medication. She said it was her expectation the order would be carried out the same or next day as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services before they could be started. She said this was the first time this had happened, and the facility did not give an explanation as to why. In an interview on 02/25/25 at 3:15 pm, The DON stated the CEO just contacted her and would not approve hospice services for Resident #1 until the hospice company contacted him personally . She said she gave the information to the hospice company. In an interview with the CEO on 02/25/25 at 4:20 pm, he stated hospice contracts had to be reviewed on a case-by-case basis. He said Resident #1 could have hospice care, but a contract had to be signed first, he said he contacted the Human Resource Director this morning to sign a contract for hospice services. When the CEO was informed it had been 8-days since Resident #1 requested hospice services at this time due to the resident being in pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services . In an interview with the CEO on 02/25/25 at 4:55 pm, he said Resident #1 had been placed on hospice services. In an interview on 02/26/25 at 1:00 pm, the Social Worker she said an acceptable time for a resident to be placed on hospice services would be 24 to 48 hours. Record review of the facility policy Resident Rights, dated a revised December 2016, revealed the following [in part]: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. self-determination f. communication with and access to people and services, both inside and outside the facility h. be supportive by the facility in exercising his or her rights s. choose an attending physician and participate in the decision-making regarding his or her care. In a record review of the facility policy Hospice Program, dated Quarter 2, 2020, revealed the following [in part]: Policy statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation: 8. When a resident has been diagnosed as terminally ill, the Director of Nursing/designee will contact the hospice agency and request that a visit /interview with the resident/family be conducted to determine the resident's wishes relative to participation in the hospice program.

Based on observation, interview, and record review, the facility failed to provide a working telephone for the residents to use. The facility failed to pay their phone vendor and phone services were terminated on 02/07/25. This failure could leave residents without the contact from their family/representative which could make them feel isolated. Findings included: Interview on 02/22/25 at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on 02/07/25 and has never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on 02/10/25 so that the residents and their families could communicate with each other. She said the residents did not have access to a facility phone from 02/07/25 to 02/10/25. Interview on 2/22/25 at 02:50 PM with family member of Resident #5 stated she has difficulty getting through to the facility as the phone will ring and no one will answer. She was not aware the phone service had been disconnected. Interview on 2/23/25 at 10:15am with LVN E stated resident's families have expressed frustration about not being able to contact the facility or their loved ones. Interview on 2/24/25 at 2:00pm with Ombudsman stated it is hard to contact the facility. She said family members have contacted her regarding their concern about the inability to call the facility. Interview on 2/27/25 at 10:25am with Social Worker stated she had resident families call her personal cell phone 2- 3 times per week for the past 3-4 weeks complaining about not being able to contact family members in the facility and stated many of them very worried about loved ones. Observation on 2/28/25 at 12:40pm this investigator tried to contact facility phone number and it gave a busy signal. Interview on 3/10/25 at 2:23pm with family member of resident #7 stated the facility phones are not working and it has made it difficult to contact her family member. Interview on 3/13/25 at 3pm with resident #14 stated the phones don't work and she cannot call her mom. Observation on 3/16/25 at 9:43am this investigator tried to contact facility phone number and it gave a busy signal. Interview on 3/17/25 at 9:05am with DON stated she calls the facility phone number from her personal cell every day to see if the phone is working because the CEO says he paid the bill, but it is not on. Observation on 3/17/25 at 9:50am investigator tried to contact facility phone number and it gave a busy signal. Record review of Resident Rights policy dated December 2016 revealed f. communication with and access to people and services, both inside and outside the facility .cc. access to a telephone, mail and email.

Based on interview and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 4 (Resident # 1, Resident #2, Resident #9, Resident #11) of 14 residents reviewed for Quality of Care. The facility failed to ensure Residents #2, #9, and #11 made it to their scheduled doctor appointments for follow up and other scheduled appointments. The facility failed to provide needed care and services in accordance with Resident #1's preferences to attain hospice services. This failure could affect the ability for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Observation on [DATE] at 1:15 pm revealed the facility Van appeared dusty inside. The registration tags expired ,d+[DATE]. In an interview on [DATE] at 10:00 am the Human Resource Director stated the van registration was not completed and had expired in December. The Human Resource Director stated it had not been renewed due to the petty cash account was not accessible. She stated no residents went out to the hospital. In an interview on [DATE] at 10:16 am the vehicle insurance company stated the policy was cancelled and would not provide the date it was cancelled. Record review of electronic file for Resident #9 revealed he was a [AGE] year-old male with admitted [DATE]. Resident #9 had diagnoses of acute on chronic diastolic (congestive) heart failure (weakening of heart when heart can't pump blood to give normal supply), type 2 diabetes mellitus with diabetic chronic kidney disease (adult onset diabetes and kidneys damaged due to high blood sugar levels), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque inside arteries causing heart disease), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of prostate gland), chronic kidney disease, stage 3 unspecified (mild to moderate kidney damage and may struggle to filter waste), pressure ulcer of right ankle, unstageable (wound where base is covered by slough making it impossible to determine true depth). The Resident was his own responsible party. In an interview on [DATE] at 10:50 am the DON stated she saw the documentation a few weeks ago that the insurance policy for the van was canceled. She stated Resident #9 had missed some doctors' appointments due to the van situation. In an interview on [DATE] at 11:00 am LVN E stated Resident #9 had an appointment on [DATE] with the nephrologist that had not been rescheduled as of this date, and an appointment with the cardiologist on [DATE] that had been rescheduled for [DATE] that were missed due to not having the facility van insurance. In an interview on [DATE] at 12:25pm CNA H stated she stopped driving residents in the van in January due to the van not having insurance. In an interview on [DATE] at 12:50 pm the DON stated there was no log of van usage because it has not been used due to no van insurance. In an interview on [DATE] at 9:00 am the vehicle insurance company stated the insurance policy was not reinstated. Record review of electronic file for Resident #2 revealed she was a [AGE] year-old female with an original admitted [DATE] with the latest return date of [DATE]. Resident #2 had diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), type 2 diabetes mellitus with diabetic chronic kidney disease (kidneys damaged due to high blood sugar levels), anemia (low iron), diverticulosis of both small and large intestine without perforation or abscess without bleeding (small bulging pouches that can form in lining of digestive tract), urinary tract infection (bladder infection). The resident was her own responsible party. In an interview on [DATE] at 9:00 am LVN A stated Resident #2 was having light vaginal bleeding and physician A wanted to see her and we could not send her due to the van not having insurance. LVN A said physician A said she would come to the facility. In an interview on [DATE] at 11:03 am the DON stated Resident #2 was having light vaginal bleeding on [DATE]; They contacted physician A and wanted her to be brought to her office but told Physician A they were not able to transport the resident due to no insurance on the van. Physician A said she would come up to the facility to see the resident but never did. The resident was transferred to theER on [DATE] via hospital ambulance. Record review of hospital record for Resident #2 reflected No new orders. Still Has UTI. All bleeding was negative. Transvaginal ultrasound was negative. All labs good. X-rays completed with no findings. Record review of electronic file for Resident #11 revealed she was a [AGE] year-old female with an admitted [DATE]. Resident #11 had diagnoses of type 1 diabetes mellitus with diabetic chronic kidney disease (juvenile diabetes and kidneys damaged due to high blood sugar levels), chronic kidney disease (kidney failure), type 1 diabetes mellitus with diabetic neuropathy (nerve damage caused by persistent high blood sugars), essential (primary) hypertension (high blood pressure), neuromuscular scoliosis, lumbar region (sideways curvature of spine), hyperlipidemia (high fat in blood), legal blindness, deficiency of other specified b group vitamins (B vitamin levels lower than normal), magnesium deficiency (levels lower than normal), vitamin d deficiency (levels lower than normal), hypokalemia (high potassium), elevation of levels of liver transaminase levels (liver damage), other seizures (uncontrolled jerking, loss of consciousness, other symptoms caused by abnormal electrical brain activity). The Resident was her own responsible party. In an interview on [DATE] at 11:00 am LVN E stated Resident #11 had an appointment scheduled for [DATE] with physician B that was missed due to not having the facility van insurance. In an interview on [DATE] at 8:24 am Physician B stated Resident #11 had an appointment with him yesterday, but the facility called and cancelled, stated they didn't have enough staff. In an interview on [DATE] at 12:00 pm Physician A stated she was not aware residents missed doctor appointments due to no insurance on the van. Physician A stated she was not informed by the facility about Resident #9's missed cardiology and kidney appointments and said those appointments were considered critical to attend. Physician A stated the facility called and Resident #2 reported bleeding from her vaginal area; Physician A said she asked them to bring her to her office, but they stated they could not due to no insurance on the van. Record review of an appointment book revealed Resident #11 missed an appointment on [DATE] with the Primary care doctor; Resident #9 missed an appointment on [DATE] with the cardiologist and it was rescheduled for [DATE]. Resident #9 missed an appointment on [DATE] with the kidney doctor. Record review of progress notes dated [DATE] by LVN E revealed Resident #11 Rescheduled residents appt today due to unable to transfer in company van. Rescheduled for [DATE] at 9:30am. Record review of Transportation, Social Services policy dated [DATE] revealed Our facility shall help arrange transportation for residents as needed. Record review of Resident #1's Admission Record dated [DATE] revealed Resident #1 was an [AGE] year-old female with an original admitted [DATE] with the latest return date of [DATE]. Resident #1 had diagnoses of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. Record review of Resident #1's Admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 12 (moderate cognitive impairment). Record review of Resident #1's care plan, dated as revised on [DATE] revealed the following [in part]:Focus: [Resident #1] has pain related to multiple myeloma, osteoarthritis, and skin blisters. Goal: The resident will not have an interruption in normal activities due to pain through the review period. Interventions: *Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. * Resident will not have an interruption in normal activities due to pain. *Comfort will be maintained. *Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #1's Physician Orders revealed the following: A. May have hospice of resident choosing, evaluate for service, start date of [DATE]. B. Tylenol with Codeine #3 tablet ,d+[DATE]mg at bedtime for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of [DATE]. C. Tylenol with Codeine #3 tablet ,d+[DATE]mg every 4 hours as needed for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of [DATE]. Record review of Resident #1's electronic record revealed Resident #1 requested hospice services on [DATE] due to uncontrolled pain. The facility physician wrote an order for hospice services on [DATE] and an order for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours as needed for pain. A progress note dated [DATE], by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. In an interview on [DATE] at 10:50 a.m., the DON said she was aware Resident #1 was expressing pain that was not resolved with current treatment. The facility Physician increased her pain medication and referred resident to Hospice on [DATE]; however, Hospice could not be obtained because it required the CEO's approval. The DON provided e-mail communication with the CEO requesting hospice services. In a record review of an e-mail dated [DATE] at 11:05 a.m., from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please begin the process to set this up? In a record review of a progress note dated [DATE] at 9:06 a.m. revealed, Resident #1 asked the LVN When is the hospice person coming to see me. In an interview on [DATE] at 9:30 a.m., Resident #1's POA said Resident #1 expressed to her on [DATE] that she wanted hospice services due to pain. She said she was told by the facility that corporate had to approve hospice care and they were waiting on that. She said she was upset and did not know why it was taking so long for Resident #1 to be placed on hospice services. In an interview on [DATE] at 10:00 a.m., the DON reported she went ahead and contacted hospice services on this date for Resident #1 without the permission of the CEO. In an interview on [DATE] at 12:00 p.m., facility Physician A said the facility contacted her on [DATE] as Resident #1 was requesting hospice services because her pain was not resolving with current regiment. She said on [DATE] she ordered for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours and referred her to hospice for more effective pain management. She said it was her expectation the order would be carried out the same day ordered if possible as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services for a resident before they would be evaluated for services. She said this was the first time that [a resident was not provided hospice directly after Physician put in order]had happened. In an interview on [DATE] at 4:20 p.m., the CEO stated hospice contracts have to be on a case-by-case basis and a contract had to be signed first. He said he contacted the Human Resource Director this morning to get a contract signed. When informed it had been 8-days since Resident #1 requested hospice services and the resident had been experiencing uncontrolled pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services. In a follow-up interview on [DATE] at 4:55 pm, the CEO reported Resident #1 was now on hospice services. Record review of Resident Rights policy dated [DATE] revealed f. communication with and access to people and services, both inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #1) residents reviewed for pain. The facility failed to manage Resident #1's pain at an acceptable level per her preference until hospice services could be obtained. It took the facility 8-days to arrange hospice services. This deficient practice could place residents at risk of increased pain, discomfort, being unable to perform daily activities, psychological effects, and a diminished quality of life. Findings included: Record review of Resident #1's Admission Record dated 02/22/25 revealed Resident #1 was an [AGE] year-old female with an original admitted [DATE] with the latest return date of 02/06/25. Resident #1 had diagnoses of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. Record review of Resident #1's Admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 12 (moderate cognitive impairment). MDS was negative for pain. Record review of Resident #1's Pain assessment dated [DATE] revealed the resident expressed pain in the last 5 days, pain was frequent, hard to sleep at night. It stated Resident #1 was ordered Tylenol #3 for 7 days on previous admission but was admitted to the hospital before regimen was completed. Medication was not reordered when Resident #1 was readmitted . Revealed resident is repositioned and is somewhat effective. Record review of Resident #1's care plan, dated as revised on 02/16/25 revealed the following [in part]: Focus: [Resident #1] has pain related to multiple myeloma, osteoarthritis, and skin blisters. Goal: The resident will not have an interruption in normal activities due to pain through the review period. Interventions: *Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. * Resident will not have an interruption in normal activities due to pain. *Comfort will be maintained. *Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Record review of Resident #1's Physician Orders revealed the following: A. Monitor for pain every shift, use 1-10 scale for alert residents and use pain aide for confused residents, document which pain scale used to assess residents pain rating, start date of 01/30/25. B. May have hospice of resident choosing, evaluate for service, start date of 02/16/25. C. Tylenol with Codeine #3 tablet 300-30mg at bedtime for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of 02/16/25. D. Tylenol with Codeine #3 tablet 300-30mg every 4 hours as needed for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of 02/16/25. Record review of Resident #1's electronic record revealed Resident #1 requested hospice services on 02/16/25 due to uncontrolled pain. The facility physician wrote an order for hospice services on 02/16/25 and an order for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours as needed for pain. A progress note dated 02/16/25, by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. In a record review of an e-mail dated 02/17/25 at 11:05 a.m., from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please begin the process to set this up? In an observation and interview with Resident #1 on 02/23/25 at 12:30 p.m., the resident was sitting up in her recliner very still and stiff and didn't move her body throughout the conversation. She expressed that she was in pain. She said that she received pain medications, but they only help a little. She said her pain was currently at a level 6. She said her pain never got below a 6 with medication, just took the edge off. She said that she would like hospice services to help with pain. She said she requested hospice services but did not know the status of hospice care. Record review of the MAR revealed the resident had received pain medication on 2/23/25 at 12:00 pm. With a follow up pain score of 2- effective at 2:20pm. Record review of Resident #1's progress notes and MAR reflected they failed to have documentation of the physician order to monitor pain every shift as ordered on 01/30/25. Record review of Resident #1's MAR for February 2025 revealed the resident did not receive her schedule Tylenol #3 at bedtime on 02/15/25 and 02/21/25. No adverse effect noted. In an interview on 02/24/25 at 10:50 a.m., the DON said she was aware Resident #1 was expressing pain that was not resolved with current treatment. The facility Physician increased her pain medication and referred resident to Hospice on 02/16/25; however, Hospice could not be obtained because it required the CEO's approval. The DON provided e-mail communication with the CEO requesting hospice services. In a record review of a progress note dated 02/24/25 at 9:06 a.m., Resident #1 asked the LVN When is the hospice person coming to see me. In an interview on 02/25/25 at 9:30 a.m., Resident #1's POA said Resident #1 expressed to her on 02/16/25 that she wanted hospice services due to pain. She said that she talks to Resident #1 daily on the phone and Resident #1 has expressed to her that she was in a lot of pain. She said she was told by the facility that corporate had to approve hospice care and they were waiting on that. She said she was upset and did not know why it was taking so long for Resident #1 to be placed on hospice services. In an interview on 02/25/25 at 10:00 a.m., the DON reported she went ahead and contacted hospice services on this date for Resident #1 without the permission of the CEO. In an interview on 02/25/25 at 12:00 p.m., the facility Physician A said the facility contacted her on 02/16/25 as Resident #1 was requesting hospice services because her pain was not resolving with current regiment. She said on 02/16/2 she ordered for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours and referred her to hospice for more effective pain management. She said it was her expectation the order would be carried out the same day ordered if possible as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services for a resident before they would be evaluated for services. She said this was the first time that had happened. Record review of Resident #1's electronic record revealed: 2/16/25 at 2:45pm, pain score of 7. PRN pain medication given, and it was effective. 2/17/25 at 4:03am, pain score of 5. PRN pain medication given, and it was effective. 2/19/25 at 8:14am, pain score of 7. PRN pain medication provided, and it was effective. 2/20/25 at 12:35am, pain score of 4. PRN pain medication provided and was effective. 2/20/25 at 3:19pm, pain score of 7. PRN pain medication provided, and it was effective. 2/21/25 at 8:47am, pain score of 7. PRN pain medication given, and it was effective. 2/23/25 at 11:49pm, pain score of 7. PRN pain medication provided, and it was effective. 2/24/25 at 9:02am, pain score of 8. PRN pain medication provided, and it was effective. 2/24/25 at 1:03pm, pain score of 7. PRN pain medication provided, and it was effective. 2/25/25 at 5:01am, pain score of 8. PRN pain medication provided, and it was effective. In an interview on 02/25/25 at 4:20 p.m., the CEO stated hospice contracts have to be on a case-by-case basis and a contract had to be signed first. He said he contacted the Human Resource Director this morning to get a contract signed. When informed it had been 8-days since Resident #1 requested hospice services and the resident had been experiencing uncontrolled pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services. In a follow-up interview on 02/25/25 at 4:55 pm, the CEO reported Resident #1 was now on hospice services. In an interview on 02/27/25 at 9:50 am, Physician A said the facility did not contact her regarding Resident #1's breakthrough pain she was experiencing. She said it was her expectation the facility should have contacted her. She said she would have prescribed something different until she was placed under hospice care. In an interview on 2/28/25 at 12:30 pm, the DON said she was not aware that Resident #1 did not receive her scheduled Tylenol #3 at bedtime on 02/15/25 and 2/21/25. In a follow up interview on 4/7/25 at 12:38pm, Physician A stated that if pain improved, she considers that effective but if not then it is not effective. Physician A said it depends on the patient. Physician A ordered hospice services for Resident #1 due to patient preference and terminal prognosis. Physician A stated Resident #1's pain is being managed now and she believes it took a minute [last break through pain noted on 2/28/25] when Hospice took over to prevent breakthrough pain. Physician A stated Hospice can provide care and comfort and that is their purpose. In an interview on 4/7/25 at 4:30pm with LVN D, she stated that Resident #1 had never told her the medications were not effective and Resident #1 could tell her if it was effective or not effective and she went by what Resident #1 told her. In an interview on 4/7/25 at 4:49pm with LVN D, she stated that she considers pain medication effective if residents tell her it is effective or if she goes back and they are asleep. She stated Resident #1 never told her it wasn't effective. A record review of the facility policy Pain assessment and Management, not dated, revealed the following [in part]: Purpose: The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Monitoring and Modifying Approaches: 1. Reevaluate the resident's pain and consequences of pain at least each shift or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the following factors to determine if the resident's pain is being adequately controlled: a. The resident's response to interventions and level of comfort over time. 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Documentation: 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain. 3. Prolonged, unrelieved pain despite care plan interventions.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (January 2025, February 2025, and March 2025) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 28 of 47 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: In a record review and interview on 02/23/25 at 10:00 am, the Human Resource Director provided the Nurse Staffing Information from January 1, 2025, to February 21, 2025. It revealed there was no RN coverage for dates of 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, 01/20/25, 01/26/25, 01/27/25, 02/01/25, 02/02/25, 02/08/25, 02/09/25, 02/15/25, and 02/16/25, 03/01/25 and 03/04/25. The Human Resource Director confirmed there was no RN coverage for the dates. She said the DON was out on medical leave and returned on 01/21/25. The DON works Monday-Friday. There is no RN coverage for the weekends, but staff can call the DON if needed. In an interview on 02/23/25 at 10:50 am, the DON said she was on medical leave and returned to the facility on [DATE]. She said during the time she was off, there was no RN coverage for the building. She said she only works Monday-Friday so there is no RN in the facility on the weekends, but staff can call her if needed. In an interview on 02/25/25 at 4:20 pm, the CEO said the DON works Monday - Friday and no one has applied for the RN position to cover the weekend. He said the DON is available by phone if needed. In an interview on 02/28/24 at 12:30 pm, the DON said possible negative outcomes of not having a RN coverage is a resident might not be accessed correctly and it would be hard to run a code. A facility policy was requested but not provided by the time of exit. A policy was requested but not provided by the time of exit.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 12 of 12 residents (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #15, #16) during medication pass. A: Resident #7 and Resident #5 did not receive medications at 8:00 am medication pass. B: CMA F administered Resident's #2, #3, #4, #6, #8, #9, #11, #15, #16 medications greater than one hour after the scheduled administration time on [DATE]. C: CMA F operated outside of her scope of practice by administering an initial dose of a narcotic to Resident #1 and assessed Resident #1's pain. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm. Findings Include: A. Resident #7 Record review of Resident #7's Admission Records, dated [DATE], revealed an [AGE] year-old female, with the latest admitted [DATE]. Diagnosis included congestive heart failure (the heart cannot pump blood effectively), dementia (progress decline in cognitive functioning), hypertension (high blood pressure), and presence of cardiac pacemaker (implanted medical device to regulate the heartbeat). Record review of Resident #7s Quarterly MDS, dated [DATE] revealed a BIMS score of 15 (cognitively intact). Record review of Resident #7's Physician's Order Summary Report dated [DATE] revealed the following orders: Amiodarone HCI for atrial fibrillation 100mg at 0800. Order date of [DATE]; Amlodipine Besylate 5mg for atrial fibrillation at 0800. Order date of [DATE]; B12 Fast Dissolve 5000mg for B12 deficiency at 0800. Order date of [DATE]; Folic acid 1mg for anemia at 0800. Order date of [DATE]; Furosemide 20mg for diastolic heart failure at 0800. Order date of [DATE]; Med plus 2.0. at 0800. Order date of [DATE]; Pantoprazole sodium 40mg for GERD at 0800. Order date of [DATE]; Potassium chloride ER 20meq for hyperkalemia at 0800. Order date of [DATE]; Probiotic acidophilus oral capsule for UTI at 0800. Order date of [DATE]; Vitamin C 1000mg for allergic rhinitis at 0800. Order date of [DATE]; Gabapentin 300mg for polyneuropathy at 0800. Order date of [DATE]; Muro 128 ophthalmic ointment 5% for eyes at 0800. Order date of [DATE]; Tropism chloride oral tab 20mg for overactive bladder at 0800. Order date of [DATE]. Record review of Resident #7's MAR for [DATE] revealed the resident did not receive the following medications on [DATE]: Amiodarone HCI for atrial fibrillation 100mg at 0800. Order date of [DATE]; Amlodipine Besylate 5mg for atrial fibrillation at 0800. Order date of [DATE]; B12 Fast Dissolve 5000mg for B12 deficiency at 0800. Order date of [DATE]; Folic acid 1mg for anemia at 0800. Order date of [DATE]; Furosemide 20mg for diastolic heart failure at 0800. Order date of [DATE]; Med plus 2.0. at 0800. Order date of [DATE]; Pantoprazole sodium 40mg for GERD at 0800. Order date of [DATE]; Potassium chloride ER 20meq for hyperkalemia at 0800. Order date of [DATE]; Probiotic acidophilus oral capsule for UTI at 0800. Order date of [DATE]; Vitamin C 1000mg for allergic rhinitis at 0800. Order date of [DATE]; Gabapentin 300mg for polyneuropathy at 0800. Order date of [DATE]; Muro 128 ophthalmic ointment 5% for eyes at 0800. Order date of [DATE]; Tropism chloride oral tab 20mg for overactive bladder at 0800. Order date of [DATE]. In an interview with Resident #7 on [DATE] at 2:45 pm, she said there was one day when she didn't get any meds but couldn't remember the day. She denied having any negative consequences due to the missed medications. Resident #4 Record review of Resident #5's Admission Record, dated [DATE], revealed an [AGE] year-old female, was a last admitted [DATE]. Diagnosis included cerebral infarction (stroke) and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS, date [DATE] revealed the resident had a BIMS score of 04 (severe impairment). Record review of Resident #5's Physician's Order Summary Report dated [DATE] revealed the following orders: Aspirin delayed release 81mg for cerebral infarction at 0800. Order date of [DATE]; Donepezil HCI 5mg for cognitive function and awareness at 0800. Order date of [DATE]; Escitalopram oxalate 20mg for major depressive disorder at 0800. Order date of [DATE]; Furosemide 40mg at 0800. Order date of [DATE]; Lisinopril oral tablet 5mg for hypertension at 0800. Order date of [DATE]; Multiple vitamins-minerals oral tablet at 0800. Order date of [DATE]; Omeprazole 20mg capsule delayed release for GERD at 0800. Order date of [DATE]; Vitamin C oral tab 1000mg for type 2 diabetes with diabetic chronic kidney disease at 0800. Order date [DATE]. 0800; Atorvastatin Calcium oral tab 80mg for hyperlipidemia. Order date of [DATE]; Carvedilol 6.25mg for hypertension at 0800. Order date of [DATE]; Docusate Sodium 100mg for constipation at 0800. Order date of [DATE]; Memantine HCI 10mg for cognitive functions and awareness at 0800. Order date of [DATE]; Senna oral tab 8.6mg for constipation at 0800. Order date of [DATE]; Verapamil HCI ER 180mg for hypertension at 0800. Order date of [DATE]; Hydralazine HCI 25mg for hypertension at 0800. Order date of [DATE]; THCG Protein powder for diabetes at 0800. Order date of [DATE]; Clonidine HCI oral tab 0.1 mg for hypertension at 0800. Order date of [DATE]. Record review of Resident #5's MAR for [DATE] revealed the resident did not receive the following medications on [DATE]: Aspirin delayed release 81mg for cerebral infarction at 0800. Order date of [DATE]; Donepezil HCI 5mg for cognitive function and awareness at 0800. Order date of [DATE]; Escitalopram oxalate 20mg for major depressive disorder at 0800. Order date of [DATE]; Furosemide 40mg at 0800. Order date of [DATE]; Lisinopril oral tablet 5mg for hypertension at 0800. Order date of [DATE]; Multiple vitamins-minerals oral tablet at 0800. Order date of [DATE]; Omeprazole 20mg capsule delayed release for GERD at 0800. Order date of [DATE]; Vitamin C oral tab 1000mg for type 2 diabetes with diabetic chronic kidney disease at 0800. Order date [DATE]. 0800; Atorvastatin Calcium oral tab 80mg for hyperlipidemia. Order date of [DATE]; Carvedilol 6.25mg for hypertension at 0800. Order date of [DATE]; Docusate Sodium 100mg for constipation at 0800. Order date of [DATE]; Memantine HCI 10mg for cognitive functions and awareness at 0800. Order date of [DATE]; Senna oral tab 8.6mg for constipation at 0800. Order date of [DATE]; Verapamil HCI ER 180mg for hypertension at 0800. Order date of [DATE]; Hydralazine HCI 25mg for hypertension at 0800. Order date of [DATE]; THCG Protein powder for diabetes at 0800. Order date of [DATE]; Clonidine HCI oral tab 0.1 mg for hypertension at 0800. Order date of [DATE] . B: Resident #2 Record review of Resident #2's Admission Record, dated [DATE], revealed a [AGE] year-old female, with a latest admitted [DATE]. Diagnosis included Alzheimer's Disease (a decline in memory, thinking, and behavior) and Hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS, dated [DATE] revealed a BIMS score of 08 (moderately impaired). Record review of Resident #2's Physician's Order Summary Report, dated [DATE] revealed the following orders: Amlodipine besylate 10mg for Hypertension at 0730. Order date of [DATE]; Cephalexin 250mg for UTI at 0730. Order date of [DATE]; Famotidine Oral tablet 40mg for indigestion at 0730. Order date of [DATE]; Hydrochlorothiazide 25mg for blood pressure and edema at 0730. Order date of [DATE]; Lexapro 5mg for depressive disorders at 0730. Order date of [DATE]; Metoprolol Succinate ER 25mg for Hypertension at 0730. Order date of [DATE]; Potassium Chloride ER 20meq for Hyperkalemia at 0730. Order date of [DATE]; Vitamin D3 tablet 2000IU for age-related osteoporosis at 0730. Order date of [DATE]; hydralazine HCI 10mg for Hypertension at 0730. Order date of [DATE]. Record review of Resident #2's MAR for [DATE] revealed the resident did not receive her 0700 medications until after 1100 on [DATE]: Amlodipine besylate 10mg for Hypertension at 0730.; Cephalexin 250mg for UTI at 0730. Order date of [DATE]; Famotidine Oral tablet 40mg for indigestion at 0730. Hydrochlorothiazide 25mg for blood pressure and edema at 0730.; Lexapro 5mg for depressive disorders at 0730. ; Metoprolol Succinate ER 25mg for Hypertension at 0730. ; Potassium Chloride ER 20meq for Hyperkalemia at 0730. ; Vitamin D3 tablet 2000IU for age-related osteoporosis at 0730. ; hydralazine HCI 10mg for Hypertension at 0730. In an interview on [DATE] at 12:00 pm, Resident #2 was ambulating in the hallway in wheelchair. She failed to answer any questions regarding medications/high blood pressure. Resident #3 Record review of Resident #3's Admission Records, dated [DATE], revealed a [AGE] year-old male, with the latest admitted [DATE]. Diagnosis included cerebral infarction (stroke), hypertension (high blood pressure), and tachycardia (heart rate exceeding 100 beats per minute while at rest). Record review of Resident #3's Quarterly MDS, dated [DATE] revealed a BIMS score of 05 (severe impairment). Record review of Resident #3's Physician's Order Summary Report dated [DATE] revealed the following orders: amlodipine Besylate 5mg for hypertension at 0700. Order date of [DATE]; Lisinopril 40mg for Hypertension at 0700. Order date of [DATE]; Buspirone HCI 10mg for anxiety at 0700. Order date of [DATE]; Glipizide 20mg for Diabetes with Chronic Kidney disease at 0700. Order date of [DATE]; MED PASS 2.0 120cc for moderate protein-calorie malnutrition at 0800. Order date of [DATE]; Metoprolol Tartrate oral tablet 25mg for hypertension at 0700. Order date of [DATE]. Record review of Resident #3's MAR for [DATE] revealed the resident did not receive his 0700 medications until after 1100 on [DATE]: amlodipine Besylate 5mg for hypertension at 0700. Order date of [DATE]; Lisinopril 40mg for Hypertension at 0700. Order date of [DATE]; Buspirone HCI 10mg for anxiety at 0700. Order date of [DATE]; Glipizide 20mg for Diabetes with Chronic Kidney disease at 0700. Order date of [DATE]; MED PASS 2.0 120cc for moderate protein-calorie malnutrition at 0800. Order date of [DATE]; Metoprolol Tartrate oral tablet 25mg for hypertension at 0700. Order date of [DATE]. Resident #4 Record review of Resident #4's Admission Records, dated [DATE], revealed an [AGE] year-old female, with the latest admitted [DATE]. Diagnoses included chronic combined systolic and diastolic heart failure (the heart to too weak and stiff to pump blood effectively) and hypertension (high blood pressure). Record review of Resident #4's Quarterly MDS, dated [DATE] revealed a BIMS score of 10 (moderately impaired). Record review of Resident #4's Physician's Order Summary Report, dated [DATE] revealed the following orders: Aspirin oral tab chewable 81mg for Chronic combined systolic and diastolic heart failure at 0800. Order date of [DATE]; Fluoxetine HCI 20mg for recurrent depressive disorders at 0800. Order date of [DATE]; Lasix tablet 40mg for diastolic heart failure at 0800. Order date of [DATE]; Potassium Chloride ER capsule 10meq for diastolic heart failure at 0800. Order date of [DATE]; Ativan 0.5mg for anxiety disorder at 0800. Order date of [DATE]; Senna Plus tab 8XXX,d+[DATE]mg for constipation at 0800. Order date of [DATE]; Artificial tears solution 1% for hypertension at 0800. Order date of [DATE]. Record review of Resident #4's MAR for [DATE] revealed the resident did not receive her 0800 medications until after 1100 on [DATE]: Aspirin oral tab chewable 81mg for Chronic combined systolic and diastolic heart failure at 0800. Order date of [DATE]; Fluoxetine HCI 20mg for recurrent depressive disorders at 0800. Order date of [DATE]; Lasix tablet 40mg for diastolic heart failure at 0800. Order date of [DATE]; Potassium Chloride ER capsule 10meq for diastolic heart failure at 0800. Order date of [DATE]; Ativan 0.5mg for anxiety disorder at 0800. Order date of [DATE]; Senna Plus tab 8XXX,d+[DATE]mg for constipation at 0800. Order date of [DATE]; Artificial tears solution 1% for hypertension at 0800. Order date of [DATE]. Resident #6 Record review of Resident #6's Admission Records, dated [DATE], revealed an [AGE] year-old male, with an admitted [DATE]. Diagnosis included dementia (loss of cognitive functioning that interferes with daily life), anxiety disorder (a group of mental health conditions characterized by excessive fear, dread, and symptoms out of proportion to the situation) and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood). Record review of Resident #6's Quarterly MDS, dated [DATE] revealed a BIMS score of 03 (severe impairment). Record review of Resident #6's Physician's Order Summary Report dated [DATE] revealed the following orders: Aspirin 81MG for hypertension at 0800. Order date of [DATE]; Magnesium oxide 400mg for indigestion at 0800. Order date of [DATE]; Omeprazole oral capsule delayed release 20mg for GERD at 0800. Order date of [DATE]; Vitamin D 50mg for vitamin D deficiency at 0800. Order date of [DATE]; Ativan 0.5mg for anxiety/agitation at 0800. Order date of [DATE]' Buspirone HCI 5mg for generalized anxiety disorder at 0800. Order date of [DATE]; Depakote ER 250mg for behaviors at 0800. Order date of [DATE]; Quetiapine Fumarate 50MG for bipolar/behavior at 0800. Order date of [DATE]. Record review of Resident #6's MAR for [DATE] revealed the resident did not receive his 0800 medications until after 1100 on [DATE] : Aspirin 81MG for hypertension at 0800. Order date of [DATE]; Magnesium oxide 400mg for indigestion at 0800. Order date of [DATE]; Omeprazole oral capsule delayed release 20mg for GERD at 0800. Order date of [DATE]; Vitamin D 50mg for vitamin D deficiency at 0800. Order date of [DATE]; Ativan 0.5mg for anxiety/agitation at 0800. Order date of [DATE]' Buspirone HCI 5mg for generalized anxiety disorder at 0800. Order date of [DATE]; Depakote ER 250mg for behaviors at 0800. Order date of [DATE]; Quetiapine Fumarate 50MG for bipolar/behavior at 0800. Order date of [DATE]. Resident #8 Record review of Resident #8's Admission Records, dated [DATE], revealed a [AGE] year-old female, with an admitted [DATE]. Diagnosis included Schizophrenia (a mental health condition that affects how people think, feel, and behave) and hypertension (high blood pressure). Record review of Resident #8's Quarterly MDS, dated [DATE] revealed a BIMS score of 14 (cognitively intact). Record review of Resident #8's Physician's Order Summary Report dated [DATE] revealed the following orders: Colchicine-Probenecid 0XXX,d+[DATE]mg for gout at 0800. Order date of [DATE]; Fenofibrate Micronized 200mg for hyperlipidemia at 0800. Order date of [DATE]; hydrochlorothiazide 12.5mg for hypertension at 0800. Order date of [DATE]; Jardiance 25mg for type II diabetes at 0800. Order date of [DATE]; Lisinopril 10mg for hypertension at 0800. Order date of [DATE]; Multivitamin-Minerals tablet for vitamin deficiency at 0800. Order date of [DATE]; Pioglitazone 30mg for chronic kidney disease at 0800. Order date of [DATE]; Vitamin D3 125mcg for vitamin deficiency at 0800. Order date of [DATE]; Combigan Ophthalmic Solution 0XXX,d+[DATE].5% for glaucoma 0800. Order date of [DATE]; Cosopt Ophthalmic Solution ,d+[DATE].5% for glaucoma at 0800. Order date of [DATE]; refresh tears ophthalmic solution 0.5% for dry eyes at 0800. Order date of [DATE]. Record review of Resident #8's MAR for [DATE] revealed the resident did not receive her 0800 medications until after 1100 am on [DATE]: Colchicine-Probenecid 0XXX,d+[DATE]mg for gout at 0800. Order date of [DATE]; Fenofibrate Micronized 200mg for hyperlipidemia at 0800. Order date of [DATE]; hydrochlorothiazide 12.5mg for hypertension at 0800. Order date of [DATE]; Jardiance 25mg for type II diabetes at 0800. Order date of [DATE]; Lisinopril 10mg for hypertension at 0800. Order date of [DATE]; Multivitamin-Minerals tablet for vitamin deficiency at 0800. Order date of [DATE]; Pioglitazone 30mg for chronic kidney disease at 0800. Order date of [DATE]; Vitamin D3 125mcg for vitamin deficiency at 0800. Order date of [DATE]; Combigan Ophthalmic Solution 0XXX,d+[DATE].5% for glaucoma 0800. Order date of [DATE]; Cosopt Ophthalmic Solution ,d+[DATE].5% for glaucoma at 0800. Order date of [DATE]; refresh tears ophthalmic solution 0.5% for dry eyes at 0800. Order date of [DATE]. Resident #9 Record review of Resident #9's Admission Records, dated [DATE], revealed a [AGE] year-old male, with an admitted [DATE]. Diagnosis included chronic kidney disease (kidneys are damaged and cannot filter blood properly) and hypertension (high blood pressure). Record review of Resident #9's Quarterly MDS, dated [DATE] revealed a BIMS score of 15 (cognitively intact). Record review of Resident #9's Physician's Order Summary Report dated [DATE] revealed the following orders: Aspirin 81mg for CVA at 0700. Order date of [DATE]; Carvedilol 6.25mg for hypertension at 0700. Order date of [DATE]; Iron oral tablet 325mg for chronic kidney disease at 0700. Order date [DATE]; Jardiance 25mg for type 2 diabetes at 0700. Order date [DATE]; Lasix 20mg for weight gain at 0700. Order date [DATE]; Losartan Potassium 50mg for chronic kidney disease at 0800. Order date [DATE]; [NAME]-Vite tablet for muscle weakness at 0700. Order date [DATE]. 0700; Tamsulosin 0.4mg for lower urinary tract symptoms. Order date [DATE]; Vesicare 5mg for lower urinary tract symptoms at 0700. Order date [DATE]; Vitamin A 10000 units for pressure ulcer to right ankle at 0800. Order date [DATE]; Vitamin D 125mcg for vitamin D deficiency at 0700. Order date [DATE]; Zinc 50mg for pressure ulcer of right ankle at 0700. Order date [DATE]; buspirone HCI 15mg for anxiety disorder at 0700. Order date [DATE]; hydralazine HCI 10mg for chronic kidney disease at 0700. Order date [DATE]; Vitamin C tablet 500mg for pressure ulcer of right ankle at 0700. Order date [DATE]. Record review of Resident #9's MAR for [DATE] revealed the resident did not receive his 0700 medications until after 1100 am on [DATE]: Aspirin 81mg for CVA at 0700. Order date of [DATE]; Carvedilol 6.25mg for hypertension at 0700. Order date of [DATE]; Iron oral tablet 325mg for chronic kidney disease at 0700. Order date [DATE]; Jardiance 25mg for type 2 diabetes at 0700. Order date [DATE]; Lasix 20mg for weight gain at 0700. Order date [DATE]; Losartan Potassium 50mg for chronic kidney disease at 0800. Order date [DATE]; [NAME]-Vite tablet for muscle weakness at 0700. Order date [DATE]. 0700; Tamsulosin 0.4mg for lower urinary tract symptoms. Order date [DATE]; Vesicare 5mg for lower urinary tract symptoms at 0700. Order date [DATE]; Vitamin A 10000 units for pressure ulcer to right ankle at 0800. Order date [DATE]; Vitamin D 125mcg for vitamin D deficiency at 0700. Order date [DATE]; Zinc 50mg for pressure ulcer of right ankle at 0700. Order date [DATE]; buspirone HCI 15mg for anxiety disorder at 0700. Order date [DATE]; hydralazine HCI 10mg for chronic kidney disease at 0700. Order date [DATE]; Vitamin C tablet 500mg for pressure ulcer of right ankle at 0700. Order date [DATE]. In an interview with Resident #9 on [DATE] at 11:22 am, he said he has received all of his medications. Resident #11 Record review of Resident #11's Admission Records, dated [DATE], revealed a [AGE] year-old female, with the latest admitted [DATE]. Diagnosis included unspecified intellectual disabilities (impaired development of learning, reasoning, social, and life skills) and hypertension (high blood pressure). Record review of Resident #11's Quarterly MDS, dated [DATE] revealed a BIMS score of 11 (cognitively intact). Record review of Resident #11's Physician's Order Summary Report dated [DATE] revealed the following orders: cyanocobalamin 500mg for vitamin B deficiency at 0730. Order date [DATE]; Kerendia 20mg for chronic kidney disease at 0730. Order date [DATE]; vitamin C 1000mg for chronic urinary tract infection at 0730. Order date of [DATE]; vitamin D3 125mcg for vitamin D deficiency at 0730. Order date [DATE]. 0730. Record review of Resident #11's MAR for [DATE] revealed the resident did not receive her 0730 medications until after 1100 am on [DATE]: cyanocobalamin 500mg for vitamin B deficiency at 0730. Order date [DATE]; Kerendia 20mg for chronic kidney disease at 0730. Order date [DATE]; vitamin C 1000mg for chronic urinary tract infection at 0730. Order date of [DATE]; vitamin D3 125mcg for vitamin D deficiency at 0730. Order date [DATE]. 0730. Resident #15 Record review of Resident #15's Admission Records, dated [DATE], revealed a [AGE] year-old female, with the latest admitted [DATE]. Diagnosis included unspecified dementia (loss of cognitive and reasoning skills) and hypertension (high blood pressure). Record review of Resident #15's Annual MDS, dated [DATE] revealed a BIMS score of 03 (severe impairment). Record review of Resident #15's Physician's Order Summary Report dated [DATE] revealed the following orders: Macrobid 100mg for UTI at 0730. Order date [DATE]; artificial tears 0XXX,d+[DATE].6% for dry eyes at 0730. Order date [DATE]; Lorazepam 0.5mg for anxiety/restlessness at 0730. Order date [DATE]. Record review of Resident #15's MAR for [DATE] revealed the resident did not receive her 0730 medications until after 1100 am on [DATE]: Macrobid 100mg for UTI at 0730. Order date [DATE]; artificial tears 0XXX,d+[DATE].6% for dry eyes at 0730. Order date [DATE]; Lorazepam 0.5mg for anxiety/restlessness at 0730. Order date [DATE] . Resident #16 Record review of Resident #16's Admission Records, dated [DATE], revealed an [AGE] year-old female, with an admitted [DATE]. Resident expired on [DATE]. Diagnosis included Alzheimer's Disease (a neurodegenerative condition that affects memory, thinking, and behavior) and hypertension (high blood pressure). Record review of Resident #16's Quarterly MDS, dated [DATE] revealed a BIMS score of 99 (severe impairment, not able to access). Record review of Resident #16's Physician's Order Summary Report dated [DATE] revealed the following orders: Lorazepam 4mg for agitation at 0600. Order date [DATE]; morphine 0.5mg for pain at 0600. Order date [DATE]; Atropine 3gts for nausea at 0600. Order date [DATE]. Record review of Resident #16's MAR for [DATE] revealed the resident did not receive her 0600 medications until after 1100 am on [DATE]: Lorazepam 4mg for agitation at 0600. Order date [DATE]; morphine 0.5mg for pain at 0600. Order date [DATE]; Atropine 3gts for nausea at 0600. Order date [DATE]. In an interview with CMA F on [DATE] at 11:50 am, she said when she came to work on [DATE], the internet was down and there was no physician orders or MAR available, and she did not feel comfortable giving medications without a MAR. She said she started passing medications as soon as she got the paper MAR at approximately 11:00 am. All morning medications were given after 11:00 am on [DATE]. CMA F said the reason Resident #4 did not receive her 0800 medications was that she was due high blood pressure medications at 1200. CMA F said the reason Resident #7 did not receive her 0800 medications was she got busy and it slipped my mind. In an interview with the DON on [DATE] at 11:03 am, she said she was off on Monday, [DATE] when the internet went down. When she came to work on [DATE], the nurses told her there was no paper copy of the MAR. She contacted the Human Resource Director to get a copy and it was received the next morning on [DATE]. Stated she was aware the resident's received their morning medications late on [DATE]. She said she was not aware Resident #4 and Resident #7 did not receive their 0800 medications on [DATE]. The DON said a potential negative outcome of a resident missing blood pressure medications is the resident could start having symptoms. She said there were no reports of any residents having negative outcomes relating to this failure. In an interview with Facility Physician B on [DATE] at 8:24 am, he was not aware or contacted by the facility on [DATE] that resident's morning medications were given late. He said he was upset and was going to contact the facility to see if he could get any blood pressure readings for those days the residents received their medications late as residents could have symptoms of high and low blood pressures. In an interview with Facility Physician A on [DATE] at 12:00 pm, said she was not contacted by the facility and was unaware on [DATE] the residents did not receive their prescribed medications. She said it was concerning to her as a resident could have had issues with their blood pressures or start experiencing symptoms. C. Resident #1 Record review of Resident #1 Admission Record dated [DATE] revealed Resident #1 was an [AGE] year-old female with an original admitted [DATE] with the latest return date of [DATE]. Resident #1 had a diagnosis of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. Record review of Resident #1's Admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 13 (cognitively intact). The presence of pain was negative on the 5-day lookback period. Record review of Resident #1's Physician Orders, dated [DATE], revealed an order for Morphine Sulfate Oral Tablet 15mg, every 6 hours as needed for pain related to Multiple Myeloma in Relapse, start date of [DATE] at 5:46 pm. Record review of Resident #1's MAR dated [DATE] - [DATE] revealed CMA F administered the first dose of Morphine Sulfate 15mg on [DATE] at 6:07 pm. The CMA assessed Resident #1's pain at a level 9. Record review of CMA F's employee file on [DATE] revealed her Certification Medication Aid certificate is current and expires on [DATE]. In an interview on [DATE] at 12:15 am, CMA F confirmed she administered Resident #1's first dose of Morphine on [DATE] at 6:07 pm and accessed her pain. CMA F stated she gives all medications, except for insulin and assesses the resident's pain. In an interview on [DATE] at 12:30 pm, the DON said she thought a CMA could administer all medications except for insulin. When asked if a CMA can assess pain, she stated I don't know. The DON said possible negative outcomes of CMA giving initial doses of medication and assessing resident's pain would be the resident could receive the wrong medication and the resident might not be assessed correctly, 1001 things could go wrong. In a follow-up interview on [DATE] at 3:25 pm, CMA F said she thought she could administer first doses of medication. She did not know assessing resident's pain was outside of her scope of practice. She said she assessed resident's pain and tell the nurses. She said she received her medication certification about a year ago. Record review of the facility policy Adverse Consequences of Medication Errors, not dated, revealed the following [in part]: 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacture specifications, of accepted professions stands and principles of the profession proving services. 6. Examples of medication errors include: a. Omission - a drug is ordered by not administered g. Wrong time 13. The Attending Physician is notified promptly of any significate error or adverse consequences. Record review of Texas Administration Code, Title 22, Part 11, Chapter 224, Rule 224.9 (The Medication Aid Permit Holder), revealed the following [in part]: (b) The following tasks may not be delegated to the Medication Aid Permit Holder unless allowed and in compliance with Chapter 225 of this title (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions): (2) administration of the initial dose of a medication that has not been previously administered to the client. Record review of Texas Administration Code, Title 22, Part 11, Chapter 224, RULE S224.8 (Delegation of Tasks), revealed the following [in part]: (c) Nursing Tasks Prohibited from Delegation By way of example, and not in limitation, the following are nursing tasks that are not within the scope of sound professional nursing judgment to delegate: (1) physical, psychological, and social assessment which requires professional nursing judgment, intervention, referral, or follow-up. Record review of the Texas Administration Code, Title 22, Part 11, Chapter 224, Rule 224.9 (Delegation of Tasks), revealed the following [in part]: (b) The following tasks may not be delegated to the Medication Aide Permit Holder unless allowed and in compliance with Chapter 225 of this title (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions): (2) administration of the initial dose of a medication that has not been previously administered to the client. Record review of the facility job description Medication Aid - Job Description, not dated, revealed the following [in part]: Job Summary: The Medication Aid is responsible for safely administering prescribed medications to residents in accordance with Texas HHSC regulations and facility policies. Their role ensures that medication administration is documented properly, and that residents' health and well-being are monitored. Key Responsibilities: *Administer oral, topical, inhalation, and other prescribed medications as permitted by Texas Medication Aid Certification. Team Collaboration & Communication: *Work under the supervision of a licensed nurse (LVN or RN).

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 7 (Resident's #2, #3, #5, #6, #7, #8, #9) of 11 residents reviewed for medication errors. 1. CMA F failed to administer Resident #2's 7:30 am blood pressure medications on 03/05/25 of Amlodipine Besylate 10mg, hydrochlorothiazide 50mg, Metoprolol Succinate 25mg, hydralazine HCI 10mg after 11:00 am. 2. CMA F failed to administer Resident #3's 7:00 am blood pressure medications on 03/05/25 of Amlodipine Besylate 5mg, Lisinopril 40mg, Metoprolol Succinate 25mg until after 11:00 am. 3. CMA F failed to administer Resident #5's 8:00 am blood pressure medications on 03/05/25 of Lisinopril 5mg, Carvedilol 6.25mg, Verapamil HCI 180mg, Hydralazine HCI 25mg, clonidine HCI 0.1mg until after 11:00 am. 4. CMA F failed to administer Resident #6's 8:00 am psychotropic medications on 03/05/25 of Depakote ER 240mg, buspirone HCI 5mg, Quetiapine Fumarate 50mg until after 11:00 am. 5. CMA F failed to administer Resident #7's 8:00 am atrial fibrillation medications on 03/05/25 of Amiodarone HCI 100mg, amlodipine besylate 5mg until after 11:00 am. 6. CMA F failed to administer Resident #8's 8:00 am blood pressure medications on 03/05/25 of hydrochlorothiazide 12.5mg, Lisinopril 40mg until after 11:00 am. 7. CMA F failed to administer Resident #9's 8:00 am blood pressure medications on 03/05/25 of Carvedilol 12.5mg, hydralazine HCI 10mg until after 11:00 am. This failure placed residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician. The findings included: 1. Resident #2 Record review of Resident #2's Admission Record, dated 03/08/25, revealed a [AGE] year-old female, with the latest admitted [DATE]. Diagnosis included Alzheimer's Disease (neurodegenerative condition that affects memory, thinking, and behavior) and Hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS, dated [DATE] revealed a BIMS score of 08 (moderately impaired). Record review of Resident #2's Physician Order Summary Report, dated 03/16/25 revealed the following orders: Amlodipine Besylate 10mg at 7:30 am for hypertension with a start date of 10/02/21, hydrochlorothiazide 50mg at 7:30 am for hypertension with a start date of 12/19/21, Metoprolol Succinate 25mg at 7:30 am for hypertension with a start date of 03/13/24, and hydralazine HCI 10mg at 7:30 am and 12:00 pm and 8:00 pm for hypertension with a start date of 06/14/23. Record review of Resident #2's MAR for March 2025 revealed the resident did not receive their 7:30 am blood pressure medications until after 11:00 am on 03/05/25: Amlodipine Besylate 10mg at 7:30 am for hypertension with a start date of 10/02/21, hydrochlorothiazide 50mg at 7:30 am for hypertension with a start date of 12/19/21, Metoprolol Succinate 25mg at 7:30 am for hypertension with a start date of 03/13/24, and hydralazine HCI 10mg at 7:30 am and 12:00 pm and 8:00 pm for hypertension with a start date of 06/14/23. In an interview on 03/15/24 at 12:00 pm, Resident #2 was ambulating in the hallway in wheelchair. She failed to answer any questions regarding medications/high blood pressure. 2. Resident #3 Record review of Resident #3's Admission Records, dated 03/16/25, revealed a [AGE] year-old male, with the latest admitted [DATE]. Diagnosis included cerebral infarction (stroke), hypertension (hypertension), and tachycardia (a heart rate exceeding 100 beats per minute at rest). Record review of Resident #3's Quarterly MDS, dated [DATE] revealed a BIMS score of 05 (severe impairment). Record review of Resident #3's Physician Order Summary Report, dated 03/16/25 revealed the following orders: Amlodipine Besylate 5mg at 7:00 am for hypertension with a start date of 02/15/23, Lisinopril 40mg for hypertension with a start date of 11/29/22, and Metoprolol Succinate 25mg at 7:00 am and 8:00 pm with a start date of 06/20/24. Record review of Resident #3's MAR for March 2025 revealed the resident did not receive their 7:00 am blood pressure medications until after 11:00 am on 03/05/25: Amlodipine Besylate 5mg at 7:00 am for hypertension with a start date of 02/15/23, Lisinopril 40mg for hypertension with a start date of 11/29/22, and Metoprolol Succinate 25mg at 7:00 am and 8:00 pm with a start date of 06/20/24. In an interview with Resident #3 on 03/16/25 at 3:10 pm, he was not interviewable. 3. Resident #5 Record review of Resident #5's Admission Record, dated 03/08/25, revealed an [AGE] year-old female, was a last admitted [DATE]. Diagnosis included cerebral infarction (stroke) and hypertension (high blood pressure). Record review of Resident #5's Quarterly MDS, date 01/10/25 revealed the resident had a BIMS score of 04 (severe impairment). Record review of Resident #5's Physician Order Summary Report, dated 03/17/25 revealed the following orders: Lisinopril 5mg at 8:00 am for hypertension with a start date of 09/30/24, Carvedilol 6.25mg at 8:00 am and 8:00 pm for Hypertension with a start date of 09/30/24, Verapamil HCI 180mg at 8:00 am and 8:00 pm for hypertension with a start date of 01/21/25, Hydralazine HCI 25mg for hypertension at 8:00 and 12:00 pm and 8:00 pm with a start date of 09/30/24, and Clonidine HCI 0.1mg at 8:00 am and 12:00 pm and 5:00 pm and 8:00 pm for hypertension with a start date of 09/30/24. Record review of Resident #5's MAR for March 2025, revealed the resident did not receive their 8:00 am blood pressure medications until after 11:00 am on 03/05/25: Lisinopril 5mg at 8:00 am for hypertension with a start date of 09/30/24, Carvedilol 6.25mg at 8:00 am and 8:00 pm for Hypertension with a start date of 09/30/24, Verapamil HCI 180mg at 8:00 am and 8:00 pm for hypertension with a start date of 01/21/25, Hydralazine HCI 25mg for hypertension at 8:00 and 12:00 pm and 8:00 pm with a start date of 09/30/24, and Clonidine HCI 0.1mg at 8:00 am and 12:00 pm and 5:00 pm and 8:00 pm for hypertension with a start date of 09/30/24. In an interview with Resident #5 on 03/07/25 at 11:49 am, when asked if she received all of her medications, she said I think so but was not positive. She did not remember receiving any medications late. Resident #6 Record review of Resident #6's Admission Records, dated 03/16/25, revealed an [AGE] year-old male, with an admitted [DATE]. Diagnosis included dementia (loss of cognitive functioning that interferes with daily life and activities), anxiety disorder (intense, excessive, and persistent worry and fear) and bipolar disorder (mental disorder characterized by periods of depression and period of abnormally elevated mood). Record review of Resident #6's Quarterly MDS, dated [DATE] revealed a BIMS score of 03 (severe impairment) Record review of Resident #6's Physician Order Summary Report, dated 03/16/25 revealed the following orders: Ativan 0.5mg at 8:00 am and 8:00 pm for anxiety/agitation with a start date of 02/26/25, buspirone HCI 5mg at 8:00 am and 8:00 pm for anxiety disorder with a start date of 02/05/25, Depakote ER 250mg at 8:00 am and 8:00 pm with a start date of 01/24/25 for bipolar disorder, and quetiapine fumarate 50mg at 8:00 am and 8:00 pm with a start date of 01/25/25. Record review of Resident #6's MAR for March 2025 revealed the resident did not receive their 8:00 am psychotropic medications until after 11:00 am on 03/05/25: Ativan 0.5mg at 8:00 am and 8:00 pm for anxiety/agitation with a start date of 02/26/25, buspirone HCI 5mg at 8:00 am and 8:00 pm for anxiety disorder with a start date of 02/05/25, Depakote ER 250mg at 8:00 am and 8:00 pm with a start date of 01/24/25 for bipolar disorder, and quetiapine fumarate 50mg at 8:00 am and 8:00 pm with a start date of 01/25/25. In an interview with Resident #6 on 03/16/25 at 3:15 pm, he was not interviewable. Resident #7 Record review of Resident #7's Admission Records, dated 03/08/25, revealed an [AGE] year-old female, with the latest admitted [DATE]. Diagnosis included congestive heart failure (the hearts ability to pump blood), dementia (loss of cognitive functioning that interferes with daily life and activities), hypertension (high blood pressure), and presence of cardiac pacemaker (an implanted medical device that prevents the heart from beating too slowly). Record review of Resident #7s Quarterly MDS, dated [DATE] revealed a BIMS score of 15 (cognitively intact). Record review of Resident #7's Physician Order Summary Report, dated 03/17/25 revealed the following orders: Amiodarone HCI 100mg at 8:00 am for atrial fibrillation with a start date of 01/30/25 and amlodipine besylate 5mg at 8:00 am for atrial fibrillation at 8:00 am with a start date of 02/07/25. Record review of Resident #7's MAR for March 2025 revealed the resident did not receive their 8:00 am blood pressure medications until after 11:00 am on 03/05/25: Amiodarone HCI 100mg at 8:00 am for atrial fibrillation with a start date of 01/30/25 and amlodipine besylate 5mg at 8:00 am for atrial fibrillation at 8:00 am with a start date of 02/07/25. In an interview with Resident #7 on 3/10/25 at 2:45 pm, she said there was one day when she didn't get any meds but couldn't remember the day. Resident #8 Record review of Resident #8's Admission Records, dated 03/08/25, revealed a [AGE] year-old female, with an admitted [DATE]. Diagnosis included Schizophrenia (a mental health condition that affects how people think, feel, and behave) and hypertension (high blood pressure). Record review of Resident #8's Quarterly MDS, dated [DATE] revealed a BIMS score of 14 (cognitively intact). Record review of Resident #8's Physician Order Summary Report, dated 03/17/25 revealed the following orders: hydrochlorothiazide 12.5mg at 8:00 am for hypertension with a start date of 01/13/25, Lisinopril 40mg at 8:00 am for hypertension with a start date of 10/04/24. Record review of Resident #8's MAR for March 2025 revealed the resident did not receive their 8:00 am blood pressure medications until after 11:00 am on 03/05/25: hydrochlorothiazide 12.5mg at 8:00 am for hypertension with a start date of 01/13/25, Lisinopril 40mg at 8:00 am for hypertension with a start date of 10/04/24. In an interview with Resident #8 on 03/07/25 at 11:18 am, she said she thinks she has received all of her medications, but not positive. She did not know if she received any medications late. Resident #9 Record review of Resident #9's Admission Records, dated 03/08/25, revealed a [AGE] year-old male, with an admitted [DATE]. Diagnosis included chronic kidney disease (the kidneys are damaged and cannot filter blood properly) and hypertension (high blood pressure). Record review of Resident #9's Quarterly MDS, dated [DATE] revealed a BIMS score of 15 (cognitively intact). Record review of Resident #9's Physician Order Summary Report, dated 03/17/25 revealed the following orders: Carvedilol 12.5mg at 7:00 am for hypertension with a start date of 01/27/23, hydralazine HCI 10mg at 7:00 am and 8:00 pm for hypertension with a start date of 06/10/24. Record review of Resident #9's MAR for March 2025 revealed the resident did not receive their 8:00 am blood pressure medications until after 11:00 am on 03/05/25: Carvedilol 12.5mg at 7:00 am for hypertension with a start date of 01/27/23, hydralazine HCI 10mg at 7:00 am and 8:00 pm for hypertension with a start date of 06/10/24. In an interview with Resident #9 on 03/07/25 at 11:22 am, he said he has received all of his medications and did not know if she received any late medications. In an interview with the CMA F, on 3/11/25 at 11:50 am, she said when she came to work on 03/05/25, the internet was down and there was no physician orders or MAR available, and she did not feel comfortable giving medications without a MAR. She said she started passing medications as soon as she got the paper MAR at approximately 11:00 am. All morning medications were given after 11:00 am on 03/05/25. In an interview with the DON on 03/16/25 at 11:03 am, she said she was off on Monday, 03/03/25 when the internet went down. When she came to work on 03/04/25, the nurses told her there was no paper copy of the MAR. She contacted the Human Resource Director to get a copy and it was received the next morning on 03/05/25. Stated she was aware the resident's received their morning medications late. She said a potential negative outcome of a resident missing blood pressure medications is the resident could have a crisis of low or high blood pressure. She said a potential negative outcome of a resident missing an antipsychotic medication would be the resident would start having symptoms. In an interview with Facility Physician B on 03/12/25 at 8:24 am, he was not aware or contacted by the facility on 03/05/25 that resident's morning medications were given late. He said he was upset and was going to contact the facility to see if he could get any blood pressure readings for those days. He said a potential negative outcome would be the resident would have instances of high or low blood pressures. In an interview with Facility Physician A on 03/12/25 at 12:00 pm, said she was not contacted by the facility and was unaware on 03/05/25 the residents did not receive their prescribed medications. She said it was concerning to her as a resident could have had issues with their blood pressures. Record review of the facility policy Adverse Consequences of Medication Errors, not dated, revealed the following [in part]: 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacture specifications, of accepted professions stands and principles of the profession proving services. 6. Examples of medication errors include: a. Omission - a drug is ordered by not administered g. Wrong time 13. The Attending Physician is notified promptly of any significate error or adverse consequences.

Based on observation, interview and record review, the facility failed to follow menus for one of one facility. The facility failed to follow their menus prepared in advance daily for 11 meals dated 2/10/25 -3/13/25. This failure could affect the residents by the menus failing to meet the residents' choices and dietary needs. Findings included: Interview on 2/22/25 at 11:15am with [NAME] B stated the facility got a truck in yesterday but the food supplies remain low. Stated the facility was out of coffee, milk, bread, sweeter. Stated the facility had to substitute meals due to not having the food on the menu. Stated they try to make it as close as possible to the menus to make sure the residents are receiving the correct nutritional value. At times the facility had no bread or milk. [NAME] B stated she purchased food for the residents out of her own pocket without reimbursement, mostly condiments, ketchup, and mustard. Observation on 2/22/25 at 11:15am of food supply closet showed food supplies low. The facility had can goods most of them dated yesterday. Dishwasher had chemicals. Had 7 days of nonperishables. Interview on 2/22/25 at 9:00am with LVN A stated residents did not have milk, coffee, hot chocolate. LVN and night staff bought it yesterday. There was no sugar free sweetener. LVN A stated the dietary manager was buying food. Interview on 2/23/25 at 10:50am with DON & Human Resource Director stated the vendor does not deliver milk due to non-payment. Observation on 2/23/25 at 12:23pm no menu posted in dining room. Residents stated food is good. Observed pork chops, mixed vegetables, mashed potatoes, roll. Record review of the residents revealed no significant weight loss. Interview on 2/24/25 at 10:45am with Dietary Manager stated the residents had $6 a day for meals. Dietary manager stated she ordered food two times a week for $480. Stated that is not enough food to be able to follow the menus. Stated they had to substitute meals. Dietary manager stated today, the meal required hamburger meat and they didn't have enough money for that, so had chicken instead. Stated the Nutritionist approved the substitutions. Stated the facility used Magic Cups instead of the shakes that were ordered for the residents and the Dietician approved the change. Stated she had purchased food out of her own pocket without reimbursement from the facility. Coffee, milk, sweet & low, tea bags, whatever is needed. Interview on 3/9/25 at 12:55pm with dietary manager stated she had to substitute chicken for roast. Roast is too expensive to buy. Interview on 3/10/25 at 9:15am with LVN E stated they never know what was being served. Stated a resident will ask sometimes, and they had to go and ask dietary. Stated they serve a lot of chicken and fish. Sometimes the activity director will provide snacks. Stated HR went and bought coffee yesterday for the residents. Observation on 3/10/25 at 9:20am showed food pantry appears low. Interview dated 3/10/25 at 10:45am with dietary manager provided substitution list. Stated she had to switch around the menus to what she was able to purchase. Stated she is placed an order today, but did not have enough money to purchase the menu and will have to substitute 2 meals. Stated with what she ordered today she was $12 over. Don't know if they will approve it or not. Dietary manager stated she switched day around to make them work. Stated her budget had not increased, or no one had told her. Stated she provided peanut butter and jelly, or meat sandwiches, or vanilla wafers as snacks. Record review of substitution log, 3/10/25 at 11:38 am. Substituted meals on: 2/10/25 - Meal Chicken breast, rice, California veggies (substituted with chili w/beans, salad, carrots, relish plate). 2/19/25 - Meal Cheeseburger on bun, French fries (substituted with vegetable lasagna, California veggies, rolls). 2/22/25 - Meal BBQ chicken, potato salad, green beans, honeybun cake (substituted with chicken/turkey, carrots, mashed potato, fruit). 2/21/25 - Meal vegetable soup, roast beef sandwich (substituted with tomato soup and turkey sandwich). 2/23/25 - meal spinach, peach cobbler (substituted with 4 way mix veg, sliced peaches). 2/24/25 - Meal fiesta beef bean casserole, Spanish rice, corn relish, pears (substituted with ham with pineapple, baked beans coleslaw, rolls, frosted strawberry cake). 2/25/25 - meal ham, baked beans, [NAME] slaw, pineapples with mandarin oranges (substituted with BBQ chicken, scalloped potatoes, green beans, rolls, Jello). 2/26/25 - green beans, frosted angel food cake (substituted with carrots, frosted yellow cake). 2/27/25 meal sweet & sour meatballs, rice, chocolate eclair (substituted with Italian sausage pizza, cherry Jello). 2/28/25 meal tomato soup, grilled cheese (substituted with chuckwagon steak, mashed potatoes, carrots). 3/9/25 Lunch Meal pot roast over $200, chocolate cream pie (substituted breaded chicken, pineapples) Dinner meal garlic pepper pork, strawberry shortcake (substituted with Salisbury steaks, frosted cinnamon cake). 3/10/25 Lunch meal brussels sprouts, raspberry peaches (substituted with broccoli mixed vegetables, raspberry applesauce) Dinner meal Ham & Cheese sandwiches with lettuce & tomato, crackers, navy bean soup, fruit cup (substituted with BBQ pork sliders, French fries, tomato & zucchini, mandarin oranges). Interview dated 3/10/25 at 11:54am with Dietician stated changed meals due to trucks not coming in. Coming at end of March. Stated change in ownership. She was at facility a few weeks ago and had concern about budget of food. Cannot do anything about upper management and budget. She stated she knew about cuts in food budget from upper management, don't have enough money to order the sufficient amount of food. She stated she was not aware of all substitutions, should be no more than 2 a week and she will reach out to facility about substitutions and to approve them. Going to have to simplify the resident's menus for breakfast due to the high price of eggs. Investigator requested dietary policy and it was not provided.

Based on interview and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies and to regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements for one of one facility. The facility failed to follow their Plan of Correction (POC) dated 1/3/25 in utilizing a pool of RNs from neighboring/sister communities to ensure RN coverage at least 8 consecutive hours/day 7 days/week for 28 days since the dated POC. The facility failed to follow their POC to review weekly RN coverage in SOC (Standard of Care meeting) by the Administrator and DON to ensure appropriate RN coverage is arranged and provided by the facility or services of facilities or RN telehealth audio and visual capabilities were arranged. The facility failed to follow their POC to discuss the quality deficiencies in monthly QAPI meetings for 3 months. This failure placed the residents at risk of oversight and management of the residents' healthcare needs and in managing and monitoring of the direct care staff which would ultimately affect resident care. Findings included: Record review of the POC dated 1/3/25 revealed the facility created a pool of Registered Nurses from neighboring/sister communities to ensure the human resources need to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The POC revealed weekly RN staffing needs would be reviewed weekly in SOC by the Administrator and DON to ensure appropriate RN coverage was arranged or services of facility RN telehealth audio and visual capabilities were arranged. Systematic failures will be discussed monthly in QAPI for 3 months to ensure effectiveness of systematic approaches. In an interview on 02/23/25 at 10:50 am, the DON said she was on medical leave and returned to the facility on [DATE]. She said during the time she was off, there was no RN coverage for the building. She said she only works Monday-Friday so there is no RN in the facility on the weekends, but staff can call her if needed. In an interview dated 3/13/25 at 10:30 am with the Human Resource Director which provided QAPI notes, stated the Medical Director and Administrator did not attend the meeting. The Human Resource Director stated we talked about it [RN coverage] but there is nothing we can do about it. There was no meeting in February. In a follow-up interview dated 3/15/25 at 2:25pm with the Human Resource Director, she stated the facility did have a pool with their sister facility, but that facility had several RNs quit. The Human Resource Director stated she had RN positions posted on a job website and stated she would provide the postings. These postings were not provided prior to exit. HR stated she monitored the coverage and reported to the CEO and COO. One QAPI meeting was held since 1/3/25 and that was on 1/24/25. The Human Resource Director further stated the February QAPI meeting was cancelled because staff had to cover because COVID was in the building. The March QAPI meeting is scheduled for next week. In an interview dated 3/15/25 at 2:02pm with the DON stated there is no pool of RNs. The SOC was not happening weekly because there is no Administrator. We [facility] used to have telehealth but that was before Thanksgiving. We are encouraged not to use it and staff don't know how to use it . The DON stated during the meeting on 1/24/25 that there was no discussion of RN coverage, and DON has no knowledge of RN positions posted online or anywhere. Record review of the SOC Meeting dated 1/24/25 provided by Human Resource Director as QAPI meeting minutes revealed DON, Human Resource Director, Activity Director, Maintenance Supervisor and Social Worker attended meeting. Meeting minutes revealed Resident Level Quality Measure Report run dated 2/9/25 for period of 1/1/25-1/31/25. No other information. No information regarding RN coverage or next QAPI meeting date. In a record review and interview on 02/23/25 at 10:00 am, the Human Resource Director provided the Nurse Staffing Information from January 1, 2025, to February 21, 2025. It revealed there was no RN coverage for dates of 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, 01/20/25, 01/26/25, 01/27/25, 02/01/25, 02/02/25, 02/08/25, 02/09/25, 02/15/25, and 02/16/25, 03/01/25 and 03/03/25. The Human Resource Director confirmed there was no RN coverage for the dates. She said the DON was out on medical leave and returned on 01/21/25. The DON works Monday-Friday. There is no RN coverage for the weekends , but staff can call the DON if needed. Record review of Quality Assurance and Improvement Committee policy undated revealed The committee will meet monthly .The committee shall track the progress of any plans of correction. Record review of indeed jobs revealed Administrator and CNA job posting for this facility but no RN posting located.

Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices. The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. This failure could place residents at risk for healthcare associated cross-contamination and infections. The findings include: Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER]. Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport. Interview on 01/02/2025 at 12:10pm the LVN C who was in-charge of facility at time of survey , stated she was unaware that clean laundry was being transported back into the building and deliveries needed to be covered to protect from cross-contamination. Interview on 01/03/25 at 1:00pm LVN C stated the facility did not have a policy for delivery of clean laundry.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024. This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days: 1. 10/26/2024 with no RN coverage. 2. 10/27/2024 with no RN coverage. 3. 11/3/2024 with no RN coverage. 4. 11/5/2024 with no RN coverage. 5. 11/13/2024 with no RN coverage. 6. 11/16/2024 with no RN coverage. 7. 11/20/2024 with no RN coverage. 8. 11/21/2024 with no RN coverage. 9. 11/22/2024 with no RN coverage. 10. 11/25/2024 with no RN coverage. 11. 11/26/2024 with no RN coverage. 12. 11/27/2024 with no RN coverage. 13. 11/28/2024 with no RN coverage. 14. 11/29/2024 with no RN coverage. 15. 12/2/2024 with no RN coverage. 16. 12/3/2024 with no RN coverage. 17. 12/4/2024 with no RN coverage. 18. 12/5/2024 with no RN coverage. 19. 12/6/2024 with no RN coverage. 20. 12/9/2024 with no RN coverage. 21. 12/10/2024 with no RN coverage. 22. 12/11/2024 with no RN coverage. 23. 12/12/2024 with no RN coverage. 24. 12/13/2024 with no RN coverage. 25. 12/16/2024 with no RN coverage. 26. 12/17/2024 with no RN coverage. 27. 12/18/2024 with no RN coverage. 28. 212/19/024 with no RN coverage. 29. 12/20/2024 with no RN coverage. 30. 12/23/2024 with no RN coverage. 31. 12/26/2024 with no RN coverage. 32. 12/27/2024 with no RN coverage. 33.12/30/2024 with no RN coverage. 34. 12/31/2024 with no RN coverage. In an interview and record review on 01/02/2025 at 2:30pm, the Human Resource (HR) provided the timecard reports for the months of October 2024, November 2024, and December 2024. The HR verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of : 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. In an interview on 01/02/2025 at 9:35am, the facility's CNO D said her understanding of the facility policy was an RN was to be on staff 8 hours a day. The CNO D stated the facility has weekend coverage for RN hours, and at this point the CNO D stated she can be reached by facility 24/7 by phone if needed. Record review of a policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, 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 personal hygiene for 4 of 8 residents (Resident #2, #3, #4 and #7) reviewed for incontinent care, in that: The facility failed to provide bowel and bladder incontinent care for Resident #2 and it resulted in reddened skin on buttocks area. The facility failed to provide bowel and bladder incontinent care for Resident #3 and it resulted in reddened skin on scrotum area. The facility failed to provide bowel and bladder incontinent care for Resident #4 and it resulted in reddened skin and an open area to buttock(coccyx) area. The facility failed to provide bowel and bladder incontinent care for Resident #7 and it resulted in burning sensation and reddened skin in testicle (scrotum) and buttock (coccyx) area. This failure could place residents at risk for skin break down, urinary tract infections, decrease in quality of life and loss of dignity. Findings included: Resident #2 Record review of face sheet dated 10/11/24 revealed Resident #2 is an [AGE] year-old female diagnosed with Chronic kidney disease, constipation. Record review of Resident #2's Careplan revised on 09/04/24, revealed, The resident needs prompt response to all requests for assistance. Record review of Resident #2's MDS assessment dated [DATE] Section C revealed BIMS of 3meaning severe cognitive impairment, Section GG revealed, maximum to moderate assist (meaning 2-person physical assistance) with all ADLs; Section H revealed always incontinent of bowel and bladder. Record review of Resident #2's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed. Observation on 10/15/24 at 6:29 AM revealed Resident #2 had redness of skin to buttocks and dried feces noted between buttocks. Resident #3 Record review of face sheet dated 10/22/24 revealed Resident # 3 is a [AGE] year-old male with a diagnosis of chronic kidney disease. Record review of Resident #3's Careplan revised 10/10/24 revealed, Bladder and Bowel Incontinence; r/t Prior CVA; Diabetes; History of UTI, Impaired Mobility; Recent Traumatic Brain Injury from fall with interventions that included: Check the resident every 2 hrs & and as required for incontinence. Wash, rinse and dry perineum. Record review of Resident #3's MDS assessment dated [DATE] Section C revealed BIMS of 15 meaning no cognitive impairment; Section GG revealed maximum to moderate assistance (meaning 2-person physical assistance) with all ADLs; Section H revealed always incontinent of bowel and bladder. Record review of Resident #3's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed. Observation on 10/15/24 at 7:33 AM revealed Resident #3's scrotum area was red. Strong smell of urine observed in resident room. Resident #4 Record review of face sheet dated 10/11/24 revealed Resident #4 is a [AGE] year-old female diagnosed with. Functional urinary incontinence, diarrhea. Record review of Resident #4's MDS assessment dated [DATE] Section C revealed no BIMS score and resident is rarely/never understood; Section GG revealed Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity; Section H revealed always incontinent for urinary and bowel continence. Record review of Resident #4's Careplan dated 07/10/24 revealed INCONTINENT: Check & Change [Resident #4] every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. She requires Total Assistance for incontinent Care. Record review of Resident #4's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed. Observation on 10/15/24 at 6:21 AM revealed Resident #4 had dried feces observed between buttock cheeks. Redness to skin was noted to coccyx and bilateral buttocks, 1in x 1in open area noted to top of coccyx. Resident #7 Record review of face sheet dated 10/21/24 revealed Resident #5 was a [AGE] year-old male diagnosed with muscle wasting. Record review of Resident #7's MDS assessment dated [DATE] Section C revealed a BIMS score of 11, indicating moderate cognitive impairment; Section GG revealed Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort regarding toileting hygiene. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, Regarding toilet transfer; Section H revealed Urinary Incontinence - Occasionally incontinent (less than 7 episodes of incontinence). Record review of Resident #7's careplan dated 10/10/24 revealed the following, [Resident #5] has bowel/bladder incontinence r/t impaired mobility and cognition. INCONTINENT: Check the resident[every] 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Record review of Resident #7's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed. Observation and interview on 10/15/24 at 6:41 AM revealed Resident #7 had yellowish brown stain noted on bed sheet beneath resident bottom; brown smear noted as well on white sheet. Resident stated, my crotch burns. Observation on 10/15/24 at 7:04 AM revealed Resident #7 taken to shower/bathroom in hall. Dark red skin was noted to testicles, groin and coccyx area upon incontinent care provided by staff. Interview on 10/13/24 at with CNA E regarding how CNAs knew what care or assistance each resident required CNA E stated I am locked out of the tablet, that is where I would normally look but I don't have access since I started yesterday. I just go by what I know from working here before. Interview on 10/13/24 at 8:11 PM with DON regarding how new hire CNAs were aware of needs and level of care for each resident, DON stated that's my fault, I am supposed to set her (CNA E) up a log in for the tablet and I haven't had time to do my DON stuff. Interview on 10/13/24 at 9:04 PM with ADM regarding training she provided to new hire CNA and how new hire CNA knew individual needs of each resident. ADM stated Oh, I didn't train on that, I just did her new hire paperwork. When asked if she did any resident care training, she stated No I didn't. She had come in a little bit early around 5 pm so I think she worked with the girls. Interview on 10/14/24 at 10:35AM with laundry attendant, she stated, laundry comes to me with a brown ring dried on the sheets and smells of urine. Record review of policy Resident Rights revised December 2016 revealed the following [in-part]: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; During an interview on 10/24/24 at 9:50AM, ADM stated she had nothing more that she could provide regarding a policy on activities of daily living or providing care to maintain good hygiene. During an interview on 10/25/24 at 4:45PM, ADM stated she had nothing more that she could provide regarding a policy on activities of daily living or providing care to maintain good hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that: Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room . Resident #1 was admitted to the hospital on 2/29/2024 with a diagnosis of hypotension (abnormally low blood pressure) due to drugs. An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. While the Immediate Jeopardy was removed on 03/08/2024 at 6:55 PM, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death. The findings included: Review of Resident #1's Admission Record, dated 3/01/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). Review of Resident #1's comprehensive care plan, dated 2/28/2024 revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate. Review of Resident #1's Medication Administration Record, dated February 2024, revealed LVN A documented a blood pressure of 121/75 on the morning of 2/29/2024. The record documented Resident #1's medication orders included: Cozaar 50 mg daily (anti-hypertensive medication) Metoprolol succinate 12.5 mg daily (anti-hypertensive medication) Furosemide 10 mg daily (diuretic medication) Tramadol 50 mg daily at bedtime for pain (opioid pain relief medication). Review of the Medication Incident Report, dated 2/29/2024 revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning. Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given. Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified. Review of Resident #1's hospital medical record, dated 2/29/2024, revealed the following [in part]: History of Present Illness Patient was given another resident's medications that included: Amlodipine 10 mg (blood pressure lowering - calcium channel blocker) Carvedilol 25 mg (blood pressure lowering - alpha-beta blocker) Isosorbide mononitrate ER (extended release) 60 mg (nitrate - blood vessel widening, preventative for chest pain) Norco 7.5 mg (Hydrocodone - opioid for pain relief) Spironolactone 25 mg (diuretic - fluid reduction) She then went unresponsive with no pulse and no breaths. By the time EMS arrives she was breathing on her own and had a pulse. She was found to be hypotensive and brought in. Clinical Impression Hypotension due to drugs. Chronic anemia associated with chronic disease. Triage: 2/29/24 at 11:20 AM - BP 59/24. In an interview on 3/01//2024 at 2:18 PM, the DON stated LVN A had made a medication error the prior day on 2/29/2024. She stated LVN A got distracted when someone was talking to her and she grabbed the wrong medication cup and gave Resident #1 the medications for another resident. She stated the medications included a blood pressure pill and Norco. The DON stated LVN A immediately told her at 10:30 AM. She stated LVN A realized what she had done when she did it. The DON stated she called Resident #1's physician at 10:33 AM, and he asked what BP medication Resident #1 had been given, which was Isosorbide 60 mg. The physician stated that was a high amount of blood pressure medication for her and to monitor her BP. The DON stated at 11:15 AM, Resident #1 was unresponsive, had no heartbeat or pulse, and oxygen was applied. The DON stated she did a sternum rub and someone called 911. The DON stated she called the physician at 11:24 AM and notified him Resident #1 was awake, alert, and on her way to the ER. The DON stated she had LVN A call and notify the resident's family. The DON stated the ADON accompanied LVN A on her next medication pass. The DON stated she completed an incident report for the med error. The DON stated LVN A was a new nurse and was hired within the last year. In an interview on 3/01/2024 at 3:40 PM, the ADON stated she had made random observations of LVN A during the past few months and there was never anything observed that gave her reason for alarm or concern. The ADON stated she did not know when the medications were being given yesterday morning or if LVN A was passing medications from the medication cart or from the medication room. The ADON stated LVN A told her what happened. LVN A was asked if she had passed any more medications since the incident and she said no. The ADON stated she went through LVN A's next medication pass with her about noon on 2/29/2024. She stated LVN A passed medications from the medication room (carried the medication cup from the medication room rather than pushing the medication cart) due to not having a full medication pass at that time. The ADON stated she observed LVN A through the whole process from start to finish. She stated she observed LVN A review the resident's medication order, open the medication cart and find the correct medication, verify the labeled medication card with the order, pop the medication from the bubble pack card into the medication cup, and take it to the resident and verify, and administered the medication. LVN A initialed the resident's electronic MAR after the medication was administered. The ADON stated the incident with Resident #1 was the only medication error that has been made since she started employment in the facility during November 2023. The ADON stated LVN A was the youngest and newest nurse, and the other licensed nurses have had more experience. The ADON stated she thought LVN A was competent and she made a mistake when she got busy. She stated LVN A needed to slow down and think about what she was doing. The ADON stated the standard of practice was to pop medications from the cards for one resident at a time. In an interview on 3/01/2024 at 4:43 PM, LVN A stated when she arrived at work on the morning 2/29/2024, the computer for the medication cart had not been charged and she had it plugged it into the outlet in the medication room. She stated she had taken a resident's vital signs and blood pressure and had placed his medications in a cup on top of the medication cart in the medication room. She stated she gathered her equipment to take Resident #1's vital signs (BP cuff, thermometer, oxygen pulse oximeter) and carried the medication cup and equipment to Resident #1 who was in the sunroom. LVN A stated she had it in her head to give Resident #1 the medications and she gave them to her and then took her vital signs. She stated it was about 10:20 AM. She stated she then went back to the medication room to enter the medications were given on the MAR when she realized what she had done. LVN A stated she immediately reported her error to the DON. Resident #1 was assessed and was later found to be unresponsive. The DON called the doctor. LVN A stated she called the family and said Resident #1 had been given the wrong medications and was on the way to the hospital. She stated the BP medication given was Isosorbide. LVN stated she felt awful about it and became tearful. She stated she would focus on the process of start to finish for one resident at a time. LVN A demonstrated how she reviewed a medication order in the electronic MAR, unlocked the medication cart and to find the medication and compared the card to the order in the computer, signed out the medication in the narcotic book if applicable, popped the medication from the card into a medication cup, replaced the medication card in the cart and locked it, gave the medication to the resident, and then returned and documented Y in the electronic MAR. LVN A stated she learned from this error and would focus and think about what she was doing. Observation and interview on 3/04/2024 at 1:45 PM with Resident #1 in the hospital revealed she was laying on her back in bed with the head of the bed elevated. She was using supplemental oxygen via nasal cannula. Resident #1 was awake, alert, and oriented. Resident #1 stated her doctor had been to the hospital to see her. Resident #1 stated she was feeling some better. She stated she had gone to the nursing facility after being in the hospital with pneumonia. Resident #1 stated she found out what had happened to her at the nursing home and stated she did not receive good care there. Resident #1 stated she planned to go to a different nursing home where her family members had both been and she had visited them. She stated she was familiar with the place. Resident #1 stated she could not walk very well anymore and hoped to receive therapy there. Resident #1 stated she took Tramadol and it helped with her hip and leg pain. She stated she had a wheelchair and a power chair and hoped to be able to use it again. In an interview on 3/05/2024 at 1:24 PM, the DON stated the ADON had observed LVN A give the entire lunch medication pass on Hall 2 and Hall 3 on 2/29/2024. She stated she did verbal counseling with LVN A on Thursday, 2/29/2024. The DON stated on Saturday, 3/02/2024 she came to the facility and did an in-service training on the medication administration policy and procedure with LVN A and gave her a suspension notice pending investigation. The DON stated the Administrator determined LVN A may need more training and needed to be taken off the schedule. The DON stated she came to the facility on Saturday and suspended LVN A's employment per the Administrator's directive. She stated the Administrator spoke with her corporate boss on 3/04/24 and he gave instruction for LVN A to have additional instruction for the medication pass with the medication pass checklist to be completed for 3 days - Thursday, Friday and Saturday. The DON stated LVN A was scheduled to return to work on Thursday 3/07/24 and the ADON would go with her during the medication pass with a checklist. The DON stated this was the first medication error LVN A had made since she started employment during November 2023. In a telephone interview on 3/06/2024 at 12:51 PM, Resident #1's physician stated he was aware of the incident and had been called immediately by a nurse at the facility. The physician stated he had been at the facility the morning of Thursday 2/29/24 before the incident. He stated Resident #1 was fine and was going to therapy. The physician stated Resident #1 became syncopal after being given the other resident's blood pressure medications. He stated she was responsive when the ambulance crew arrived to transport her to the ER. The physician stated the safety concern for Resident #1 was her blood pressure going too low and making her pass out. He stated the other medications did not have huge concerns (pain and diuretic medications). He stated the BP medications were the main concern. Review of the facility's policy and procedure for Medication Administration, dated 1/2013 revealed the following [in part]: Purpose: To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route. Equipment: Medication as ordered Administration supplies as indicated Procedure: 1. Verify physician's orders for medications to be administered. 2. Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient. Review resident/patient allergies. Review pertinent lab results, as indicated . Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose). 3. Identify resident/patient via wristband or picture ID. 4. Explain the procedure to the resident/patient. Include the type of medication ordered, the reason, frequency, and route . 10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time . 13. Verify the following, again, by comparing medication to MAR prior to administering: Correct resident/patient Correct medication Expiration date Dose and dosage form Route Time . This was determined to be an Immediate Jeopardy on 3/07/2024. The Administrator was provided the Immediate Jeopardy Template on 3/07/2024 at 5:15 PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility and accepted on 3/08/2024 at 4:37 PM: 1. Resident #1 was immediately assessed by the Licensed Nurse (LN) on 02/29/24 and the physician was notified of the medication error with a new order to monitor the resident's blood pressure closely. The order was noted by the LN. When the LN went to monitor Resident #1 after receiving the order, the resident was found unresponsive. The LN called EMS which responded quickly, and the resident was discharged to the ER for observation on 02/29/24. 2. The 24-hour report was reviewed on 3/7/24 by the Assistant Director of Nursing (ADON) for the past 72 hours to ensure there were no further medication errors and/or changes in any resident's condition. Any concerns will be addressed by a LN if identified. The results of the report covering the past 72 hours found no additional medication errors or changes in residents' condition. No further physician notification of actions by the licensed nurse was necessary. 3. When the Director of Nursing (DON) interviewed the LN on 02/29/24 who made medication error, it was determined that the LN dispensed the medication for a resident other than resident #1. She then realized that she needed to take resident #1's blood pressure, and subsequently also gave the other resident's medication to resident #1. The education provided to this LN by the DON included avoiding distractions and completing the medication pass one resident at a time once starting the medication administration process. Beginning 3/6/24, LNs and Certified Medication Aides (CMAs) will have a medication pass observation completed by a Registered Nurse (RN) prior to the beginning of their next shift and receive education as needed for any concerns identified by the RN conducting the observation. The RN will observe a minimum of 50% of the LNs or CMAs medication pass for that scheduled time to validate competency. The RN will stop the LN or CMA if they identify a problem and provide immediate reeducation in real time on the issue identified. The medication administration observations will be documented on the facility's Medication Administration/Technique Observation tool which follows the facility's Medication Management policy. On 3/8/24, the LNs and CMAs went through additional medication administration education that was provided by the ADON. This education included avoiding distractions to the medication pass and once starting to dispense medication for a resident, not to stop and perform any other non-emergent tasks. It also included following the facilities procedure on Medication Administration from the facilities Nursing Procedure Manual. The LNs and CMAs understanding of the education will be demonstrated through RN observed medication administration observations previously described. All newly hired LNs and CMAs will go through medication pass validations by a LN with the tools mentioned above during their orientation. 4. The DON, ADON or designee will complete med pass observations weekly for 12 weeks to ensure licensed nurse and medications aides continue to administer medications per physician's orders and to the right resident. The Medical Director was notified of this survey outcome on 3/8/24 and will be involved in the facility QAPI process surrounding this plan. A report of the medication administration audits will be submitted to the QAPI committee for review and recommendations as needed. The facility held an initial QAPI meeting on 3/8/24 to review the outcome of the medication administration observations to this point. Starting the week of March 11, 2024, a QAPI meeting will be conducted weekly for 4 weeks then monthly. The DON is responsible for monitoring and additional actions to this plan if needed. Date of Compliance: 03/08/24 Monitoring and verification of the facility's Plan of Removal began on 3/08/2024 at 4:40 PM as follows: Observation on 3/06/2024 at 11:46 AM revealed the DON was observing LVN C passing medications and was using a medication administration competency checklist. In an interview on 3/06/2024 at 11:52 AM, the DON stated she did medication administration competency checklist for LVN C. She stated the MDS Coordinator had observed LVN D and did the medication competency on her. The DON stated they were the only 2 LVNs at the facility. She stated 6 more LVNs would be evaluated for medication administration competency. The DON stated LVN A would have 3 days of evaluation using the medication checklists. She stated tomorrow and Friday (3/07/24 and 3/08/24) the ADON would observe LVN A and complete the medication administration checklist and on Saturday, 3/09/24 the weekend RN would observe LVN A and complete the medication administration checklist. In an interview on 3/07/2024 at 2:32 PM, the MDS Coordinator stated she had evaluated LVN D and completed the medication checklist with her yesterday on 3/06/2024. During an observation and interview on 3/07/2024 at 4:03 PM, MA E was observed during the preparation of medication to administer to a resident. She stated she would not take the medication cart down the hallway, due to only having medication for 1 resident. MA E reviewed the resident's medication orders in the electronic medication administration record, unlocked the medication cart and located the medication card, popped the medication into a medication cup, returned the medication card to the cart, and locked the medication cart. She proceeded to walk down the hallway to the resident's room carrying the medication cup and a glass with water, and stated she identified the resident by her picture on the medication administration record and by her room number. MA E identified herself to the resident, explained the pills she had brought for the resident, tapped the pills from the medication cup into the resident's mouth, and offered her the glass of water. MA E left the resident's room and walked back to the medication cart, pulled up the resident's medication administration record, initialed the medication had been given, and closed the electronic medication administration record. During an observation and interview on 3/07/2024 at 4:40 PM, LVN B was observed during the preparation of medication to administer to a resident who was seated at a table in the dining room. The LVN pushed the medication cart from the medication room and positioned the cart against the wall to the right of the entrance to the dining room. LVN B stated she took the medication cart into the halls when she had the main medication pass, but sometimes just carried the medication cup and a glass of water to the resident if it was only one resident. LVN B reviewed the medication order in the resident's electronic medication administration record. The resident's picture was in the upper left-hand corner of the medication administration record. LVN B unlocked the medication cart, found the medication card and compared it to the order on the medication administration record. She popped one tablet from the medication card into a medication cup, returned the medication card into the medication cart, and locked the cart. LVN B hit the screen saver on the computer, took the medication cup and a glass of water to the resident and watched her swallow the medication. She returned to the medication cart and entered the medication administered on electronic medication administration record and closed the record. In an interview on 3/08/2024 at 11:02 AM the ADON stated she was accompanying LVN A during the medication passes for the day. Review of the fax cover sheet dated 3/08/2024 at 1:41 PM revealed the Administrator had sent the Medical Director a notification letter regarding the medication error, a copy of the IJ Template and the facility's draft Plan of Removal. Review of the in-service training record dated 3/08/2024 at 2:00 PM revealed a training was provided to the licensed nurses regarding the topic of medication management and the facility's policy and procedure for medication error preventing and reporting. The attendance sheet was signed by a medication aide, 5 LVNs, and the weekend RN. In an interview on 3/08/2024 at 5:37 PM, LVN B stated the ADON had watched her pass medications yesterday on 3/07/2024. LVN B stated the nurses had in-service training that day at 2:00 PM and the topics covered were medication errors, the types of medication errors - giving the wrong medication or transcription errors in orders, using the 5 Rights of Medication administration, and avoiding distractions when preparing medications for administration. Observation on 3/08/2024 at 5:48 PM revealed the ADON was accompanying LVN A on the medication pass in Hall 2. The medication cart was in the hallway. Review of the QAPI Meeting Sign-in Sheet, dated 3/08/2024 at 3:00 PM, revealed the committee discussed the IJ Plan of Removal for medication error. During an interview and record review on 3/08/2024 at 4:26 PM, the ADON provided a copy of the 72 Hour Summary report dated 3/04/24 - 3/07/24. She stated the 24-hour report was printed from the program used for the residents' electronic health records and included new orders, progress notes, weights and vital signs. She stated there was not a way to filter all the information that was included in the report. The ADON stated the MDS Coordinator reviewed the 24-hour report in the morning, Monday through Friday, and she sent an email to the Administrator, DON, ADON, and therapy staff with any concerns or anything that needed follow-up. Review of the copy of the 72 Hour Summary report revealed it consisted of 32 pages and the first page had been signed as reviewed by the ADON on 3/07/24 at 1900 (7 PM). The 72 Hour Summary report had 10 hand-written documented notations for vital signs and weight changes that had been rechecked. [This interview and record review were conducted prior to the acceptance of the final draft of the Plan of Removal.] The Administrator was informed the Immediate Jeopardy was removed on 3/08/24 at 6:55 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.