Every finding on record at Hayward Health Services

Based on interview and record review, the facility did not ensure resident (R) was cared for in a manner to enhance their quality of life (R1).Facility staff administered diuresis medication of Furosemide 80 mg (milligrams) at 8:48 AM and Furosemide 80 mg at 10:10 AM. before R1 was going to an appointment outside the facility premises where R1 could not properly be toileted when needed. R1 suffered 3 incontinent episodes and became emotionally upset and affected by the incontinence episodes.Findings include:R1 was admitted to the facility on [DATE] with diagnoses including, in part, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disorder (COPD), pleural effusion, acute respiratory failure with hypoxia, and hypertension.R1's Minimum Data Set (MDS) assessment, dated 07/16/26, indicated R1 had Brief Interview of Mental Status (BIMS) score of 15/15, which means intact cognition.R1's urinary incontinence related to decreased mobility and receiving large doses of diuretics during the day, care plan states:-Administer medication per provider orders initiated on 12/23/24.-Provide incontinent care as needed on 12/23/24. R1's Activities of Daily Living (ADL) care plan, states, in part: -Toileting: assist of 2 using bed pan initiated on 12/23/24. -Transfer: mechanical lift using XXL size sling initiated on 05/13/26.R1's physician treatment orders:-Furosemide Oral Tablet 40 MG (Furosemide), Give 2 tablet by mouth two times a day related to CHF started on 12/21/24.Facility schedule identified R1's counseling appointment was at 1:00 PM, with transportation pick up time at 12:30 PM.R1's Medication Administration Record (MAR) identified R1 was given Furosemide 80 mg on 07/13/26 at 8:48 AM and then second dose at 10:10 AM.On 07/28/26 at 11:01 AM, Surveyor entered R1's room to interview R1. Surveyor asked R1 if they asked facility not to give them the diuretic before their counseling appointment on 07/13/26. R1 reported to Surveyor they have been going to counseling once a month for the last year and nursing staff usually will hold the diuretic pill until they get back to the facility between 1:30-2:00 PM. On 07/13/26, a nurse gave R1 the diuretic pill before their counseling appointment which then led to R1 urinating in pants 3 times. R1 stated, There is no way for the counseling office to transport me, as I am a Hoyer lift. R1 returned to the facility upset. R1 stated, I get really emotional when I pee my pants, and I don't know why the nurse would do this to me. While R1 was speaking to Surveyor, Surveyor observed R1 become emotional and their eyes welling up with tears. Surveyor asked R1 if staff was upset or rude with them for the incontinent urine episode upon returning to facility with a wet brief. R1 reported to Surveyor the staff were not upset at all with them but were concerned about their skin condition. R1 reported to Surveyor facility staff changed them right away.On 07/28/26 at 11:37 AM, Surveyor entered Nursing Home Administrator (NHA) A's office with Regional Director of Nursing (DON) C, and DON B. Surveyor asked Regional DON C and DON B if Surveyor could have them review R1's MAR (Medication Administration Record) for 07/13/26 with Surveyor. Surveyor observed Furosemide 80 mg given at 8:48 AM and 10:10 AM. Surveyor asked DON B if administering R1's Furosemide 80 mg prior to their counseling appointment, was appropriate when where there was no way for the counseling center to transfer R1 to a toilet while at appointment. DON B reported to Surveyor R1's Furosemide should have been held prior to their appointment since they only last about an hour, then they would not have had to experience the incontinent episodes while out of the facility.

Based on observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R) reviewed (R1).Staff did not follow physician orders to manage R1's Congestive Heart Failure (CHF) diagnosis in managing fluid overload. Staff did not notify provider of R1's weight fluctuations as ordered. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), pleural effusion, acute respiratory failure with hypoxia, and hypertension. R1's Minimum Data Set (MDS) assessment, dated 07/16/26, identified R1 had Brief Interview of Mental Status (BIMS) score of 15/15, which means intact cognition. R1's Activities of Daily Living (ADL) care plan states: -Toileting: assist of 2 using bed pan initiated on 12/23/24. -Transfer: mechanical lift using XXL size sling initiated on 05/13/26. R1's Edema/excess fluid volume as evidenced by need for scheduled diuretics care plan, states: -Report signs and symptoms of edema/fluid overload, such as change in mental status, weight gain, neck vein distention, abnormal lung sounds, and extremity swelling initiated on 12/23/24. -Weight three times weekly initiated on 01/14/25. R1's physician treatment orders: -Furosemide Oral Tablet 40 MG (Furosemide), Give 2 tablet by mouth two times a day related to CHF started on 12/21/24. R1's Medication Administration Record (MAR) identified: -R1 was given both AM and 12:00PM dose of Furosemide equaled to 160 mg on 01/12/26 at 1:31 PM. -R1 was given Furosemide 80 mg on 03/05/26 at 9:25 AM and then second dose at 12:10 PM. -R1 was given Furosemide 80 mg on 07/13/26 at 8:48 AM and then second dose at 10:10 AM. R1's weight identified: -On 07/06/26, R1 weighed 274.6 lbs. -On 07/08/26, R1 weighed 258.0 lbs. Surveyor could not find documentation that the facility staff notified provider of R1's weight loss. -On 07/10/26, R1 weighed 257.0 lbs. -On 07/13/26, R1 weighed 274.6 lbs. Surveyor could not find documentation that the facility staff notified provider of R1's weight gain of a 3lb increase in a day or 5lb increase in a week. -On 07/14/26, R1 weighed 278.6 lbs. Surveyor could not find documentation that the facility staff notified provider of further weight gain of a 3lb increase in a day or 5lb increase in a week. On 07/28/26 at 12:55 PM, Surveyor interviewed Certified Nurse Assistant (CNA) E and asked process for weighing residents on the wheelchair scale. CNA E reported to Surveyor CNA E's process is once a month the staff will weigh all residents' wheelchairs and document on a spreadsheet the current wheelchair weight. Then CNA E starts the shift with weights needed for the day and will gather weights from the residents. Surveyor asked CNA E how they weigh R1. CNA E reported wheelchair scale is zeroed out, then R1 is wheeled to the wheelchair scale, pulled onto scale backwards with pedals if it applies, and then a weight is taken for R1. Surveyor asked CNA E who reviews R1's weights. CNA E reported to Surveyor the nurse in charge reviews R1's weights. Surveyor asked CNA E if they worked yesterday on Monday 07/27/26. CNA E reported to Surveyor they did not work yesterday. Surveyor asked CNA E if they were aware R1 did not receive a weight as physician ordered to do so on Monday, Wednesday, and Friday, three times a week. CNA E reported to Surveyor they did not know R1 did not receive a weight yesterday on 07/27/26. Surveyor asked CNA E if it was in a report that R1 still needed a weight performed for accurate management of R1's CHF with diuretic administration. CNA E reported to Surveyor no one informed or reported to CNA E of the need to weigh R1 today on 07/28/26. On 07/28/26 at 1:00 PM, Surveyor interviewed CNA F and asked for the process for weighing residents on the wheelchair scale. CNA F reported to Surveyor their process is once a month the staff will weigh all residents' wheelchairs and document on a spreadsheet the current wheelchair weight. Then CNA F will gather weights from the residents throughout CNA F's shift. Surveyor asked CNA F who reviews residents' weights. CNA F reported to Surveyor the nurse in charge reviews all residents' weights. Surveyor asked CNA F who oversees calibrating the facility wheelchair scale. CNA F reported to Surveyor, Maintenance Director D checks calibration of wheelchair scale and not the aides. On 07/29/26 at 1:04 PM, Surveyor interviewed Maintenance Director D and asked who calibrates wheelchair scale. Maintenance Director D reported company comes in yearly to recalibrate and last visit was 10/30/25. Maintenance Director D reported the last calibration resulted with only 4/10ths of a decimal off and the company recalibrated successfully with no issues. On 07/28/26 at 1:09 PM, Surveyor interviewed Director of Nursing (DON) B and asked about R1's weight discrepancies and expectation for staff if discrepancies are found. DON B reported to Surveyor, DON B's expectation would be the nurses reviewing R1's weights should and R1 should have been reweighed on 07/08/26, 07/13/26, and 07/14/26. Once reweighed and observed same weight in lbs., then the nurses should notify the provider on call right away so that there could be interventions put into place to manage R1's CHF and edema. DON B reported to Surveyor with the almost 20lb increase between 07/08/26 and 07/13/26, staff should have reweighed R1 and contacted a provider right away if this was accurate. Surveyor asked DON B if there was a reweigh for R1. DON B stated no.

Based on observation, interview and record review, the facility did not ensure pharmaceutical services (including procedures that ensure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (R) observed receiving the diuretic medication Furosemide (R1).-R1 was given both AM and 12:00 PM dose of Furosemide equaled to 160 mg on 01/12/26 at 1:31 PM.-R1 was given Furosemide 80 mg on 03/05/26 at 9:25 AM and then second dose at 12:10 PM.-R1 was given Furosemide 80 mg on 07/13/26 at 8:48 AM and then second dose at 10:10 AM.Findings include:Facility document titled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection states in part, .Procedures: 1. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis.R1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), pleural effusion, acute respiratory failure with hypoxia, and hypertension.R1's Minimum Data Set (MDS) assessment, dated 07/16/26, indicated R1 had Brief Interview for Mental Status (BIMS) score of 15 /15 indicating R1 had intact cognition.R1's physician treatment orders:-Furosemide Oral Tablet 40 MG (Furosemide), Give 2 tablet by mouth two times a day related to CHF started on 12/21/24.R1's Medication Administration Record (MAR) identified:-R1 was given both AM and 12:00 PM dose of Furosemide equaled to 160 mg on 01/12/26 at 1:31 PM.-R1 was given Furosemide 80 mg on 03/05/26 at 9:25 AM and then second dose at 12:10 PM.-R1 was given Furosemide 80 mg on 07/13/26 at 8:48 AM and then second dose at 10:10 AM.On 07/28/26 at 11:31 AM, Surveyor attempted to call Registered Nurse (RN) G to interview regarding reasoning for administering Furosemide medication so close together. Surveyor was unable to speak with RN G. On 07/28/26 at 11:37 AM, Surveyor entered Nursing Home Administrator (NHA) A's office with Regional Director of Nursing (DON) C, and DON B. Surveyor asked Regional DON C and DON B if Surveyor could have them review R1's MAR for the month of July with Surveyor. DON B observed on 01/12/26, R1 was given a double dose of Furosemide, on 03/05/26, R1 was given both AM and 12:00 PM dose of Furosemide within 2.5 hours apart, and on 07/13/26, R1 was given both AM and 12:00 PM dose of Furosemide within 1.25 hours apart. Surveyor asked DON C if the administrations of Furosemide given on 01/12/26, 03/05/26, and 07/13/26 were normal administration times and did facility recognize these as medication errors. DON B reported to Surveyor, a diuretic such as Furosemide medication for R1, should be staggered to at least 4 hours in between doses. DON B stated RN G should not have given R1 the second dose on 03/05/26 and 07/13/26. DON C stated to Surveyor upon review of R1's MAR, staff missed the medication error from 01/12/26 and staff should not have given a double dose of Furosemide together.

Based on observation, record review and interview, the facility did not have a system in place to ensure snack/nourishment refrigerators on the unit are maintained to prevent the potential for foodborne illness. The facility practices had the potential to affect all 33 residents. Per facility guidelines attached to resident refrigerator titled Attention all residents and family members, We are happy to provide a refrigerator to our resident's food that you provide for them outside of the facility. However, there are new specific guidelines that we need to enforce for the protection of all of our residents. It stated in part, Any food placed in the resident refrigerator must be clearly marked with the resident name and dated with a new USED BY DATE. On 12/17/2025 at 9:35 AM, Surveyor observed a plastic container with sliced vegetables and labeled with R33's name and dated 12/09/25 stored in resident refrigerator located in dining room. On 12/17/2025 at 9:43 AM, Surveyor interviewed Kitchen District Manager J regarding outdated container of vegetables located in resident refrigerator located in dining room who stated the items should have been discarded per guidelines on refrigerator door.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all 33 residents in the facility. COVID positive resident (R) did not have a sign outside R door indicating Transmission Based Precautions (TBP) were in place. Facility staff did not don and doff Personal Protective Equipment (PPE) appropriately. Staff did not sanitize hands or place a barrier while providing nebulizer care. Clean linens were not covered for two of carts in the facility's laundry room and personnel had open beverage in work area touching clean gown used to handle clean linen. Findings include: Example 1 State Operations Manual, Implementation of Transmission-Based Precautions reads in part, .When a resident is placed on transmission-based precautions, facility staff should implement the following: Clearly identify the type of precautions and the appropriate PPE to be used. Place signage that includes instructions for use of specific PPE in a conspicuous location outside the resident's room (e.g., on the door or on the wall next to the doorway), wing, or facility wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering should be included in signage. Ensure that signage also complies with residents' rights to confidentiality and privacy. On 12/15/25 at 10 AM, Surveyor noted on facility Matrix, R19 was marked as being COVID positive and on Transmission Based Precautions (TCP). Surveyor observed R19 did not have any signage outside R19's door indicating TBP. Surveyor interviewed Certified Nursing Assistant (CNA) K who reported being told R19 was found to be positive over the weekend. R19 was admitted to the facility on [DATE] with a diagnosis including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage. R19 was tested and diagnosed positive for COVID on 12/13/25. On 12/16/2025 at 2:20 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation following TBP/COVID positive protocol and having a sign outside R19's door. DON B reported of being aware there was not a droplet precaution sign on R19's door when R19 was COVID positive on 12/13/25 and did not place a sign indicating R19 was on droplet precautions until after Surveyors arrived at facility on 12/15/25. Example 2 On 12/16/2025 at 12:58 PM, Surveyor observed CNA F, donning appropriate PPE, which included an N95 mask, and enter R31's room who is under TBP for Covid to collect meal tray. Surveyor observed CNA F exit R31's without PPE including no N95 mask in place. Example 3 On 12/15/2025 at 9:09 AM, Surveyor observed RN H donning PPE for droplet precautions for a COVID positive room, and RN H entered R9's room. Surveyor observed PPE cart stocked with gowns, gloves, N95, surgical masks, and goggles. On 12/15/25 at 9:16 AM, Surveyor observed RN H walk out of R9's room without N95 mask on and the vital machine. RN H laid down contaminated goggles and piece of paper on the PPE cart, then donned gloves and began sanitizing stethoscope, goggles, and vital equipment on the rolling machine. Surveyor did not observe RN H exit droplet precaution room with N95 on. Surveyor did not observe RN H re-sanitize top of PPE cart. On 12/15/25 at 11:12 AM, Surveyor interviewed RN H and asked what the sequence is for doffing PPE in a droplet precaution room. RN H reported that all PPE gets taken off in the contaminated room before RN H exits. Surveyor asked RN H if it is normal practice placing contaminated items on top of the PPE cart and then not sanitizing the top before leaving R9's room. RN H reported that RN H should not have done that. Example 4 On 12/15/25 at 9:27 AM, Surveyor observed Certified Nurse Assistant (CNA) K doff surgical mask and place on PPE cart. CNA K donned PPE such as gown, N95 mask, goggles and gloves then entered R9's room. On 12/15/25 at 9:31 AM, Surveyor observed CNA K exit R9's room with no PPE on. CNA K placed old surgical mask on that was lying on contaminated PPE cart, then donned gloves and sanitized goggles. On 12/16/25 at 11:47 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for doffing sequence before staff are to exit droplet precaution rooms as Surveyor observed CNAs taking contaminated goggles and exiting droplet precaution rooms and lying on the top of PPE cart. DON B reported that all staff should be sanitizing goggles and placing in a brown paper bag with their names labeled on it and storing in the PPE cart. Example 5 On 12/15/25 at 9:47 AM, Surveyor observed CNA K approach PPE cart outside R19's room. CNA K doffed surgical mask and placed surgical mask face side up where the mouth covering is exposed. CNA K donned PPE and entered R19's room. CNA G also donned PPE and entered R19's room. On 12/15/25 at 9:52 AM, Surveyor observed CNA F come out of room with no PPE on and throw contaminated goggles on top of PPE cart on top of CNA K's used surgical mask and then don gloves and wipe down the goggles. Surveyor observed CNA K take breakfast tray out of room and hand it to CNA F. CNA K exited R19's room without N95 mask on. CNA K sanitized hands and went to grab contaminated surgical mask, but Surveyor stopped her to prevent spread of infection. On 12/15/25 at 9:52 AM, Surveyor interviewed CNA K and asked if it was normal to place used surgical mask on top of PPE cart. CNA K reported usually, I throw mine away. Surveyor asked CNA K is it normal to place contaminated goggles on top of PPE cart to prepare to sanitize and if it is normal to come out of droplet room with no N95 on. CNA K reported that CNA K was unsure the process but this is how I have always done this. Surveyor asked CNA K if top of PPE cart is ever sanitized. CNA K reported that CNA K is unsure, and that CNA K has never wiped it down. On 12/16/25 at 11:47 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for doffing sequence before staff are to exit droplet precaution rooms. DON B reported that all PPE is doffed before exiting the room. Surveyor asked DON B what guideline facility follows for PPE usage and that staff are being observed doffing all PPE before exiting Covid-19 positive rooms including N95 masks. DON B reported to Surveyor that DON B was unaware of that being an issue. Surveyor reported to DON B that the CDC guidelines indicate N95 masks should be doffed after exiting droplet precaution room to protect the staff member from further contamination. DON B reported to Surveyor that DON B will get trash cans outside the doors and reeducate staff. Example 6 On 12/15/25 at 10:24 AM, Surveyor observed Registered Nurse (RN) H enter R7's room without sanitizing hands. Surveyor followed RN H to observe. RN H walked into R7's room and took nebulizer mask off R7's face. RN H walked over to sink and set nebulizer mask in the contaminated sink and took pieces apart. Surveyor did not observe RN H place a barrier against the sink to protect nebulizer mask from germs. Surveyor observed RN H rinse the nebulizer mask and then place on paper towel on bedside table. RN H walked out of R7's room without sanitizing hands. On 12/15/25 at 10:25 AM, Surveyor interviewed RN H and asked if RN H sanitized hands before entering R7's room and touching nebulizer mask after exiting another room. RN H reported to Surveyor that RN H did not sanitize hands and forgot. Example 7 The facility's policy titled, Laundry Handling & Processing Policy, reads in part, .Clean linens should be sorted, packaged, transported, and stored in a manner that prevents the risk of contamination by dust, debris, or other soiled items. On 12/17/25 at 10:30 AM, during tour with Accounts Manager/Head of Laundry O, Surveyor observed Laundry Staff P obtain a gown draped over a table containing an open water container, don the gown and proceed to take laundry from one of the two open laundry carts placed in front of the running dryer and fold the laundry. On 12/17/25 at 10:32 AM, Surveyor interviewed Accounts Manager/Head of Laundry O, who stated the clean laundry carts should be covered and the staff should not have personal/open beverages in the work/clean laundry area.

Based on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADL) for 2 of 12 residents (R7 and R29) reviewed. During one observation of a nebulizer treatment provided to R7, the nurse providing cares did not speak to R7 or explain what procedure they were going to provide.During one observation of insulin administration provided to R29, the nurse providing the administration did not speak or explain what procedure nurse was going to provide to R29 and did not remove R29 from the dining prior to administering insulin. This is evidenced by:Facility policy titled, Residents Rights, dated reviewed on July 2022 states in part: .Residents will be treated with respect and dignity and care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality. Example 1R7 was admitted to the facility on [DATE], with diagnoses including chronic pulmonary disease, pleural effusion, dysphagia, weakness, acute respiratory failure with hypoxia, non-pressure ulcer of right calf limited to breakdown of skin, morbidly obese, schizoaffective disorder, hypertensive heart disease, congestive heart failure, major depressive disorder, post traumatic disorder, and presence of left artificial knee joint. R7's Minimum Data Set (MDS) assessment, dated 10/14/19, identified on admission that R7 had a Brief Interview for Mental Status (BIMS) score of 15/15. This indicated R7 had intact cognition. The MDS assessment also identified R7 required substantial maximal assist with transfers. On 12/15/25 at 9:38 AM, Surveyor observed Registered Nurse (RN) H go into R7's room and administer a nebulizer. RN H exited R7's room. On 12/15/25 at 10:20 AM, Surveyor observed Director of Nursing (DON) B walk by R7's room and noticed the nebulizer was completed. DON B kept walking by and then stopped in front of another door to ask RN H to go stop R7's nebulizer as it's completed.On 12/15/25 at 10:24 AM, Surveyor observed RN H enter R7's room without sanitizing hands. Surveyor followed RN H to observe. RN H walked into R7's room and took nebulizer mask off R7's face. R7 did not wake up. RN H did not announce RN H's self or explain the procedure to R7. On 12/15/25 at 10:34 AM, Surveyor observed RN H enter R7's room with stethoscope. Surveyor did not hear RN H announce herself to resident or explain procedure to R7 about auscultating lung sounds. When Surveyor walked by room to observe from the outside door, Surveyor only observed RN H place stethoscope against R7's upper left shoulder and listen. Surveyor did not observe RN H ask R7 to sit forward so that RN H could perform auscultation adequately to fully hear R7's lungs. Surveyor observed RN H then exit R7's room.On 12/15/25 at 10:41 AM, Surveyor interviewed R7 and asked if R7 woke up when RN H was in room listening to lung sounds. R7 reported to Surveyor that R7 did not hear anyone come in and listen to R7's lungs and did not know that occurred. On 12/15/25 at 1:12 PM, Surveyor interviewed RN H and asked why RN H did not announce self and explain the procedure occurring to R7. RN H reported that R7 is a heavy sleeper. RN H seemed to not have a concern with not announcing or explaining procedure to R7. On 12/16/25 at 12:11 PM, Surveyor interviewed DON B and asked expectation for RN H to announce herself and explain what procedures are being done before performing them on residents. DON B reported to Surveyor that all procedures are to be explained to residents prior to performing. DON B's expectation would be that RN H should have announced herself and explained what was going on to R7. Example 2R29 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinsonism, dysphagia, abnormalities with gait and mobility, unsteady on feet, dementia, type 2 diabetes mellitus, hypothyroidism, and hypertensive chronic kidney disease stage 1-4. R29's MDS assessment, dated 12/02/25, identified on admission that R29 had a BIMS score of 04/15. This indicated R29 had severe impaired cognition. On 12/15/2025 at 11:52 AM, Surveyor observed RN H walk up to R29 in the dining room with an insulin pen. RN H did not announce to R29 what RN H was doing. RN H then lifted R29's shirt on left arm and administered insulin pen to R29. RN H then walked away from R29 and headed to medication cart. Surveyor did not observe RN H explain the procedure to R29 about administering the insulin pen and Surveyor did not observe RN H ask R29 was it ok to administer the insulin pen in front of others in the dining room. On 12/15/25 at 1:12 PM, Surveyor interviewed RN H and asked what RN H's process is for administering insulin in the dining room and asking permission to R29 if administering in dining room was ok. RN H reported to Surveyor that usually RN H will pull everyone else out of dining room and provide privacy if requested before administering insulin in the dining room. RN H reported that RN H did not explain the insulin administration to R29 or ask R29 permission because R29 does not really know what is going on and didn't think he would understand anyways. On 12/16/25 at 12:11 PM, Surveyor interviewed DON B and asked expectation for administering insulin in the dining room. DON B reported to Surveyor that all nurses should be taking residents out of the dining room when administering insulin for privacy unless nurses ask residents if they are ok with administering insulin in the dining room. DON B reported that RN H should have taken R29 out of dining room.

Based on record review and staff interview, the facility did not ensure 1 resident (R7) of sampled 12 residents has the right to retain personal possessions, including furnishings, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.Facility did not allow R7 to have personal refrigerator in R7's room.Findings include:Facility policy titled, Residents Rights, dated reviewed on July 2022 states in part: .Resident has the right to retain personal possessions, including furnishings, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.R7 was admitted to the facility on [DATE] with diagnoses including chronic pulmonary disease, pleural effusion, dysphagia, weakness, acute respiratory failure with hypoxia, non-pressure ulcer of right calf limited to breakdown of skin, morbidly obese, schizoaffective disorder, hypertensive heart disease, congestive heart failure, major depressive disorder, post traumatic disorder, and presence of left artificial knee joint. R7's Minimum Data Set (MDS) assessment, dated 10/14/19, identified on admission that R7 had a Brief Interview for Mental Status (BIMS) score of 15/15. This indicated R7 had intact cognition. The MDS assessment also identified R7 required substantial maximal assist with transfers. On 12/15/2025 at 10:11 AM, Surveyor interviewed R7 and asked if R7 had any concerns in the facility. R7 reported to Surveyor that staff are great but only complaint is R7 is not allowed to have a personal fridge in R7's room. R7 stated, My boyfriend brought a fridge in my room. I was told that state does not allow personal fridges in resident rooms, so facility made my boyfriend take it back. Surveyor asked R7 who told R7 this from the facility and who did R7 report the concern of R7's fridge being taken out of room. R7 stated, I reported my concern to a nurse who was taking care of me, can't remember her name. The old administrator who was here previously had spoken with me and refused to let me keep my fridge in my room. All I want in my fridge is to keep my pop in there, that the facility allows me to have. On 12/17/25 at 9:07 AM, Surveyor interviewed Maintenance Director N and Kitchen District Manager J about refrigerator in R7's room. Kitchen District Manager J reported that Kitchen District Manager J heard that R7 brought a fridge but was asked to send back home with boyfriend. Kitchen District Manager J is not directly involved with resident refrigerators as it would be responsibility of the facility staff and not the contracted kitchen staff. Kitchen District Manager J reported the kitchen does not have a set policy regarding personal refrigerators in resident rooms, but there is a resident fridge in the dining room where residents can bring food in from outside the facility and store in the dining room. Maintenance Director N reported to Surveyor that residents don't have refrigerators in their rooms due to limited space and then everyone will want a fridge. Maintenance Director N reported there is a resident fridge in the dining room that everyone is allowed to store their food in. On 12/17/25 at 9:25 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked if NHA A was aware of R7's request and denial of a personal fridge in R7's room. NHA A reported that NHA A is aware as when NHA A started in this position at facility on 08/04/25, the old interim NHA reported to NHA A that R7 was not allowed to have fridge in R7's room due to not having the ability to keep the temp checks and items assessed on a regular basis. Surveyor explained to NHA A that it is R7's resident right to be able to have a personal fridge in their room if they want and the facility's obligation to set up a system that R7 can have refrigerator in R7's room safely. NHA A reported to Surveyor that NHA A understood.

Based on interview and record review, the facility did not ensure that every resident has the right to make choices about aspects of their life in the facility that are significant to them for 1 of 12 residents (R7) residents reviewed for choices. R7 requests to staff that R7 wants to smoke outside, and facility has refused to take R7 out due to staffing issues or too busy. Findings include:Facility policy titled, Smoking, dated reviewed on 05/09/2019, states in part: .Procedure: #11. For supervised smokers: b. A smoking schedule will be developed to provide supervision for dependent smokers. Dependent smokers will be assisted during these times.R7 was admitted to the facility on [DATE] with diagnoses including chronic pulmonary disease, pleural effusion, dysphagia, weakness, acute respiratory failure with hypoxia, non-pressure ulcer of right calf limited to breakdown of skin, morbidly obese, schizoaffective disorder, hypertensive heart disease, congestive heart failure, major depressive disorder, post traumatic disorder, and presence of left artificial knee joint. R7's Minimum Data Set (MDS) assessment, dated 10/14/19, identified on admission that R7 had a Brief Interview for Mental Status (BIMS) score of 15/15. This indicated R7 had intact cognition. The MDS assessment also identified R7 required substantial maximal assist with transfers. Surveyor reviewed R7's smoking care plan, initiated on 02/12/25, which states in part:Will have staff member go out with resident when she requests a cigarette.Surveyor reviewed R7's Assessments Nicotine Assessment, dated on 02/12/25, which states in part, Wants to at least smoke once a day. Risks benefits given. Supervised with staff when smoking. Time will be determined by staff. On 12/15/25 at 10:41 AM, Surveyor interviewed R7 and asked if R7 has any complaints. R7 reported to Surveyor that R7 wishes the facility had more staffing, and that staff would take R7 out to smoke when requested. Surveyor asked R7 what happens when R7 requests to go smoke. R7 reported to Surveyor that staff usually tell her they are busy or short staffed and can't take her out at that time, and then R7 must wait. R7 reported, Sometimes I don't get to go out at all, haven't been out in over a week, and I crave it. Surveyor reported to R7 that Surveyor will investigate the smoking concern. On 12/15/25 at 3:31 PM, Surveyor observed R7 ask several staff at the nurse's station if R7 could go outside to smoke. Registered Nurse (RN) reported to R7 that staff are short at this moment; one Certified Nurse Assistant (CNA) is covering both hallways until other CNA comes back on floor from break. R7 complained that R7 never gets to go out when R7 asks. Staff reported to R7 that when they have time, they will take R7 out. On 12/17/25 at 12:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked if a smoking schedule is set up for supervised residents such as R7 per facility smoking policy. DON B reported that staff do not set up a schedule for R7 with smoking and staff try to take R7 whenever they can. DON B reported that the Business Office takes residents out to smoke Monday through Friday while at work at least once a day to help staff. On 12/17/25 at 12:41 PM, Surveyor interviewed Medical Records Coordinator (MRC) G and asked if R7 gets to go outside to smoke and when the last time R7 has been out. MRC G reported to Surveyor that up until yesterday, 12/16/25, no residents have been out to smoke due to weather in a week and a half. Surveyor asked if R7 was taken out on Monday, 12/15/25, to smoke after R7 requested since temperature was warmer than normal. MRC G reported, I did not take her out to smoke, so I am unsure. On 12/17/25 at 1:07 PM, Surveyor interviewed Regional Director C and asked if staff offer R7 any other means such as nicotine patches to curb the craving for cigarettes while R7 did not get to go for a smoke outside. Regional Director C reported that Regional Director C will go find out right away. On 12/17/25 at 1:41 PM, Regional Director C returned to conference room and let Surveyor know that R7 was not offered any other means to curb R7's craving for cigarettes.

Based on observation, interview and record review, the facility did not ensure that a resident (R) received treatment and care to address the resident's mobility needs in accordance with professional standards of practice for 1 out of 4 residents reviewed for mobility, range of motion, and/or positioning (R2).The facility did not provide services to increase and/or prevent further decrease in mobility for R2, who required assistance with ambulation. Findings include:R2 was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, unsteadiness on feet, and weakness. R2's Minimum Data Set (MDS) assessment, completed on 12/2/25, indicated R2 scored 10/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognition. MDS assessment also indicated R2 required use of a walker, supervision and touch assistance with ambulation. R2's care plan, last revised on 11/27/24, stated R2 will walk with assistance of device/person on level surface. Nursing Restorative: Walking Program #1 Assist me with one person and gait belt and walker with (wheelchair) w/c to follow if needed, to and from each meal as I can tolerate every day.Certified Nursing Assistant (CNA) Kardex states, AMBULATION/LOCOMOTION: Assist of 1 with gait belt and 4ww (wheeled walker), Independent with propelling wheelchair for distance.CNA tasks checklist from 12/3/25 to 12/15/25 indicated task of walking R2 was documented as the following, Resident refused 15 times, supervised ambulation 6 times, independent - no touching 3 times, moderate help 1 time, not attempted due to safety concerns 4 times, and not applicable 1 time. On 12/15/25 at 1:32 PM, Surveyor interviewed R2 who reported staff do not offer to walk him to the dining room and/or back from the dining room. The staff does not offer to walk with him every day, but maybe once or twice a week. R2 denies refusing ambulation due to pain and reports he would like walk to and from the dining room for meals every day, but the staff do not have time.On 12/16/25 at 8:46 AM, Surveyor observed R2 remained in bed when breakfast trays were passed in dining room and hall. After passing trays, CNA K went into room and woke up R2 and then left to care for another resident. On 12/16/25 at 8:49 AM, Surveyor interviewed R2 who reported he has not been offered to ambulate this morning or last evening. On 12/16/25 at 1:40 PM, Surveyor interviewed CNA F and CNA K who stated residents don't always get offered ambulation because there is not enough time for them to do it on day shift. CNA K reported assistance to ambulate was offered to R2 today after breakfast and R2 asked if he could when he was done getting ready (shaving). CNA K stated yes and had not gotten a chance to go back to assist R2 to ambulate. Surveyor asked CNA F and CNA K if charting is marked refused even when residents are not offered to ambulate and both CNAs replied, Sometimes.On 12/16/25 at 2:15 PM, Surveyor interviewed [NAME] President of Services (VPS) D, who stated the expectation would be that residents receive ambulation to and from the dining room if that is what they want and is in their care plan.On 12/17/25 at approximately 2 PM, Surveyor interviewed R2 who reported he still has not been offered to be assisted in ambulation. R2 stated he would like to walk more and does not get the chance to walk at mealtimes or even daily. During the survey period from 12/15/25 to 12/17/25, Surveyor observed R2 self-propel himself or get pushed in wheelchair to and from dining room for three meals observed. Surveyor did not observe any staff offer to assist or encourage R2 to ambulate.On 12/17/25 at 2:25 PM, Director of Nursing (DON) B stated if R2's care plan indicates R2 should be ambulated to and from the dining room, then R2 should be encouraged and offered to be ambulated to and from the dining room. Surveyor requested a printed copy of R2's care plan and received a revised version that excluded a focus area and/or goal addressing R2's mobility/ambulation.

Based on observation, interview and record review, the facility did not ensure a resident with a pressure injury received care necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents (R) reviewed for pressure injuries (23).R23's care plan interventions of repositioning to heal and prevent worsening of a pressure injury were not implemented.R23's physician orders to treat a pressure injury were not implemented. The facility policy titled, Turning and Repositioning, dated 12/06/22 states: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. The policy further identifies Explanation and Compliance Guidelines in part .:1. Facility residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed.3. The frequency of turning and repositioning will be documented in the resident's place of care, and will be determined by the resident's assessments including but not limited to:a. Level of activity, moisture, and mobility/Braden Scale.b. Skin condition.c. Overall medical conditions or diagnosesd. Treatment goals.e. Type of pressure redistribution support surface in use (turning and positioning is still required on specialty surfaces, but frequency may be reduced)f. Comfort levels.4. The efficacy of repositioning should be monitored and revisions to the care plan considered, if the individual is not responding as expected to the repositioning interventions.The facility policy, titled, Clean Dressing Change, dated 07/20/2022 states: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's order will specify type of dressing and frequency of changes.R23 was admitted to facility on 10/06/20222 and has diagnoses that include diabetes mellitus type 2 with chronic kidney disease.R23's Significant Change Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) of 15/15 (cognitively intact), does not resist cares, and is dependent on staff for repositioning and transfers. R23's Braden Scale for predicting pressure sore risk completed by facility on 10/01/25 indicates a score of 14 (moderate risk).R23's Braden Scale for predicting pressure sore risk completed by facility on 12/11/2025 indicates a score of 10 (high risk).On 10/09/25, the facility conducted a weekly pressure injury tracker identifying the pressure area #1 on coccyx with measurements of 1.5 cm x 0.25 cm x 0 cm and stage II ulcer. The facility documented under comments section, Wound is denuded skin without drainage. Area around the wound is reddened and excoriated. Zinc oxide and sacral Mepilex applied. Monitor for worsening. Patient is on 2 hour turns and changes throughout the night to prevent further skin breakdown.On 12/11/25, the facility conducted a weekly pressure injury tracker identifying the pressure areas #1 on coccyx with measurements of 0 cm x 0 cm x 0 cm and stage II ulcer. The facility documented under comments section, This wound is not open, but is very red, angry looking and sometimes has areas that tend to bleed through the skin due to being so irritated. Staff cleans with soap/water and pats dry with a towel and applies Vaseline with every toileting/change.R23's care plan dated 10/06/25 with a goal of pressure ulcer showing signs of healing and remain free from infection by/through review date with interventions that include: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. The resident needs encouraged and assistance to turn/reposition at least every 2 hours, more often as needed or requested.On 12/12/25, R23 was seen at wound clinic who prescribed a plan: Patient is incontinent and suspect this is likely cause of skin irritation and infection. Triad paste and sacral Mepilex. Nystatin powder to groin and peri area.On 12/12/25, the facility put in a nurses note that stated: Returned from wound clinic appointment with new orders for mepilex to sacrum, change 3x weekly and PRN if soiled. Moisturize right [NAME] QD (every day), Nystatin powder QD to groin, buttocks and gluteal folds. Attempted to call wound clinic x 3 to get a clarification on Triad paste order, no answer, PCP faxed request for clarification.On 12/15/25, the facility put in a physician order, Cleanse sacrum with normal saline. Apply Triad paste for protection, reapply Mepilex to sacrum every 3 days and as needed if soiled at bedtime every 3 days for wound care to start on 12/16/25.On 12/15/2025 at 8:47 AM, Surveyor observed R23 sitting in a recliner eating breakfast. Constant observation by surveyor conducted and noted the following:On 12/15/2025 at 10:54 AM, R23 remained in same position in recliner.On 12/15/2025 at 12:05 PM, R23 remained in same position in recliner.On 12/15/2025 at 12:40 PM, Surveyor interviewed R23 who was sitting in same position in recliner eating lunch. R23 stated she sleeps in bed at night. Surveyor asked what time R23 got up this morning and was placed in recliner. R23 indicated had a shower around 8:00 AM and then was placed in recliner. Surveyor asked if staff assisted R23 in getting out of recliner since being placed in recliner, and R23 stated, No. Surveyor asked R23 if bottom is getting sore, and R23 stated, Yes, and I pooped. (Call light on left side of recliner arm within reach.)On 12/15/2025 at 12:56 PM, Surveyor observed a staff member enter R23's room to pick up dinner tray and heard staff member state, I will get someone to help. On 12/15/2025 at 1:02 PM, Surveyor observed another staff member enter R23's room and exit. Surveyor interviewed R23 who stated, I told them I needed to go to the bathroom.On 12/15/2025 at 1:06 PM, Surveyor observed Certified Nursing Assistant (CNA) F and CNA K using mechanical lift and laying down R23 in bed. During transfer, Surveyor observed a brown stain on a sheet covering waffle type cushion on recliner and per CNA F it was BM (bowel movement). CNA F and CNA K positioned R23 in bed and conducted incontinence care. Surveyor observed feces leaking through pants and incontinent brief. After removal of pants, Surveyor observed R23's entire area of sacral area excoriated from above coccyx to below upper thigh areas in various shades of pink to some purplish hue and CNA F confirmed the observation. CNA F stated ulcer is improving but stated was not aware of what cause of the skin break down is from.Surveyor observed no Mepilex dressing on R23's sacrum area, and R23 exhibited signs of discomfort during incontinence care of BM removal from sacral area. (Of note, facility received an order for Mepilex on 12/12/25 and did not update physician orders until 12/16/25.)On 12/15/2025 at 1:30 PM, Surveyor observed, per resident request, CNA F and CNA K reposition R23 onto right side placing a pillow behind back. During observation, both CNA F and CNA K stated they have not repositioned resident since after receiving shower this morning by CNA I and believe this was around 8:30 AM.Surveyor interviewed CNA F and CNA K regarding care plan interventions in place for R23. The CNAs stated we offer R23 to lay down after meals, rotating side to side, keep brief loose for air.On 12/16/2025 at 8:35 AM, Surveyor observed Registered Nurse (RN) L with assistance of CNA K conducting wound care treatment on R23's sacrum which included applying a Mepilex dressing. RN L stated the Triad paste order was new as of yesterday.On 12/16/2025 at 2:48 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation of R23 not being offloaded/repositioned for over 4 hours on 12/15/25. DON B stated the expectation would be for staff to follow the plan of care.During interview with DON B, Surveyor shared observation of Mepilex not in place on 12/15/25 during incontinence care as ordered by wound clinic on 12/12/25. DON B stated would need to look into this.On 12/16/2025 at 3:19 PM, DON B stated the order for Mepilex was not transcribed into system as the facility was awaiting clarification of the wound clinic order of 12/12/25 but would have expected to place the Mepilex.

Based on observations, record review and staff interviews, the facility did not ensure 1 of 1 resident (R) reviewed who required oxygen and respiratory care was provided such services consistent with professional standards of practice, the resident's comprehensive person-centered care plan, and physician orders (R7). Findings include:Example 1R7 was admitted to the facility on [DATE] with diagnoses including chronic pulmonary disease (COPD), pleural effusion, dysphagia, weakness, acute respiratory failure with hypoxia, non-pressure ulcer of right calf limited to breakdown of skin, morbidly obese, schizoaffective disorder, hypertensive heart disease, congestive heart failure, major depressive disorder, post traumatic disorder, and presence of left artificial knee joint. R7's Minimum Data Set (MDS) assessment, dated 10/14/19, identified on admission that R7 had a Brief Interview for Mental Status (BIMS) score of 15/15. This indicated R7 had intact cognition. The MDS assessment also identified R7 required substantial maximal assist with transfers. Surveyor reviewed R7's physician orders for respiratory, which state in part, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) -1 inhalation inhale orally via nebulizer two times a day for shortness of breath.O2 per nasal cannula at 2L - every shift for COPD.Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) -3 ml inhale orally every 4 hours as needed for SOB related to COPD.Surveyor reviewed R7's care plan, which states in part, R7's Activities of Daily Living (ADL) self-care deficit care plan initiated dated on 12/23/24, Need for assist related to decreased mobility:Please make sure that my O2 tank is full before I leave my room for the day and before I go to appointments R7's respiratory impairment care plan related to: Dx of COPD E/B Need for continuous O2, scheduled inhalers, initiated on 12/23/24, states in part, Evaluate lung sounds and VS as needed. Report abnormalities to MD. O2 per NC continuously at 2LPM Provide assistance with ADLs to conserve energy. On 12/15/25 at 9:38 AM, Surveyor observed Registered Nurse (RN) H go into R7's room and administer a nebulizer. RN H exited R7's room.On 12/15/25 at 10:01 AM, Surveyor observed R7 with nebulizer on empty but still going. RN H was not in room with R7. On 12/15/25 at 10:20 AM, Surveyor observed Director of Nursing (DON) B walk by R7's room and noticed the nebulizer was completed. DON B kept walking by and then stopped in front of another door to ask RN H to go stop R7's nebulizer as it's completed.On 12/15/25 at 10:24 AM, Surveyor observed RN H enter R7's room without sanitizing hands. Surveyor followed RN H to observe. RN H walked into R7's room and took nebulizer mask off of R7's face. R7 did not wake up. RN H walked out of R7's room.On 12/15/25 at 10:31 AM, Surveyor followed RN H down the hall and interviewed RN H about Surveyor not observing RN H auscultate R7's lungs for assessment prior to administering nebulizer and did not observe post nebulizer assessment. RN H reported to Surveyor that RN H should have performed a pre assessment of lungs prior to administering nebulizer to R7 and will go perform post assessment now. Surveyor asked RN H what the time frame for RN H is to go back in and check R7 with an active nebulizer being administered. RN H reported to Surveyor that RN H usually goes back in within 5-10 minutes, but RN H did not. On 12/15/25 at 10:34 AM, Surveyor observed RN H enter R7's room with stethoscope. Surveyor did not hear RN H announce herself to resident or explain procedure to R7 about auscultating lung sounds. When Surveyor walked by room to observe from the outside door, Surveyor only observed RN H place stethoscope against R7's upper left shoulder and listen. Surveyor did not observe RN H ask R7 to sit forward so that RN H could perform auscultation adequately to fully hear R7's lungs. Surveyor did not observe RN assess all 4 areas for lung sounds. Surveyor observed RN H then exit R7's room.On 12/15/25 at 10:41 AM, Surveyor interviewed R7 and asked if R7 woke up when RN H was in room listening to lung sounds. R7 reported to Surveyor that R7 did not hear anyone come in and listen to R7's lungs and did not know that occurred. On 12/16/25 at 12:11 PM, Surveyor interviewed DON B and asked expectation for RN H to complete a pre and post assessment of R7's lungs when administering a nebulizer. Example 2On 12/16/25 at 9:38 AM, Surveyor observed Certified Nursing Assistant (CNA) F enter R7's room to assist R7 to beside commode with EZ-Stand. Surveyor observed CNA F remove R7's oxygen and place R7 on commode.On 12/16/2025 at 9:48 AM, Surveyor observed RN E enter R7's room after CNA F transferred R7 off the bedside commode back to wheelchair. RN E checked R7's oxygen (O2) saturations and noted the result was 86. Surveyor asked RN E why R7's oxygen was low, and RN E reported that staff just transferred R7 to commode and must have taken it off. Surveyor asked RN E if R7 is supposed to have continuous oxygen on or can she take off during transfers. RN E reported that R7 should really have the oxygen on continuous. Surveyor had RN E check big concentrator to see what the oxygen level was at as Surveyor noticed it was between 2 and 3 liters (L). RN E reported to Surveyor that the concentrator was almost to 3 L O2 and should only be at 2 L. RN E bumped the concentrator down to 2 L. On 12/16/25 at 10:00 AM, Surveyor interviewed CNA F and asked CNA F if R7 had oxygen on during transfer to bedside commode to use the bathroom. CNA F reported to Surveyor that CNA F took oxygen off while transferring to bedside commode and then to wheelchair. CNA F reported to Surveyor that once R7 was on bedside commode, CNA F checked the portable tank and noticed it was empty, and then other CNA went to fill it up. CNA F placed R7 back into wheelchair and then applied big concentrator oxygen to R7. On 12/16/25 at 10:12 AM, Surveyor observed RN E re-enter R7's room and stopped the nebulizer machine. RN E assessed post lung sounds and gathered O2 saturation that resulted in 90 on 2 L of O2. RN E wheeled R7 into activity room and left the room. Surveyor stayed in activity room to observe R7 during activities for any possible trouble breathing since O2 was lower than normal parameters. On 12/16/25 at 10:47 AM, Surveyor interviewed RN E and asked RN E what R7's baseline O2 saturations should be that staff know to keep O2 above to prevent hypoxia. RN E reported that RN E is unsure and will need to look in R7's Electronic Health Record (EHR). RN E reviewed R7's EHR and could not find a physician order for R7's oxygen saturation parameters.On 12/17/25 at 10:54 AM, Surveyor interviewed DON B and Regional Director C and asked how staff assess respiratory status, O2 saturations and parameters for baseline since there is not a physician order to guide staff. Surveyor asked how staff decide when to decrease or increase oxygen on concentrator. Surveyor informed DON B and Regional Director C of the observation of low oxygen saturation of 86% with R7's concentrator being at 3 L. DON B and Regional Director C reviewed R7's physician orders and care plan and noted that R7's electronic health record (EHR) did not have a physician order for parameters to keep R7 above a certain oxygen saturation to prevent hypoxia. Regional Director C reported that Regional Director C would get a physician order right away.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents (R29) reviewed.Facility failed to discontinue Trazadone for R29 after pharmacy recommended R29 to discontinue if no sleep concerns. Findings include:R29 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinsonism, dysphagia, abnormalities with gait and mobility, unsteady on feet, dementia, type 2 diabetes mellitus, hypothyroidism, and hypertensive chronic kidney disease stage 1-4. R29's Minimum Data Set (MDS) assessment, dated 12/02/25, identified on admission that R29 had a Brief Interview for Mental Status (BIMS) score of 04/15. This indicated R29 had severe impaired cognition. MDS on 12/02/25 states no behaviors noted. Surveyor reviewed R29's physician orders, which state in part, Trazodone HCl Oral Tablet (Trazodone HCl) -Give 25 mg by mouth at bedtime for insomnia related to depression. Antidepressant medication - observe for sedation, drowsiness, dry mouth, blurred vision, headache, urinary retention, tachycardia, muscle tremors, agitation, skin rash, and excess weight gain. R7's care plan: Sleep cycle issues as evidenced by (difficulty falling or staying asleep) r/t medical status and cognitionUse of TrazodoneAdapt environment related to noise levels, lights, etc. Administer medications as ordered Attempt psychotropic drug reduction per MD orders - Evaluate sleep pattern Monitor for factors that may contribute to poor sleep pattern. Offer back rub, relaxation techniques, and soft/relaxing music Update MD regarding changes in resident's sleep pattern Surveyor reviewed R29's pharmacy monthly reviews:On 04/21/25: Recommendation is if R29 sleeping well to discontinue the trazadone to minimize total number of medications. On 08/13/25: Attempt reduction of Trazadone 25mg QHS. Signed by RN H on 08/29/25. Surveyor reviewed CNA task list which had order to monitor R29 every 2 hours for sleep disturbances. Surveyor did not find any consistent nightly documentation of sleep behaviors every two hours. Surveyor did not find any sleep concerns documented for the last 30 days. Surveyor reviewed R29's Sleep Assessment:On 01/18/25: Sleep assessment completed. Summary: Resident slept well since his admission during the night. No restlessness noted during the night.On 12/17/25 at 9:02 AM, Surveyor asked Director of Nursing (DON) B and Regional Director C for documentation of sleep patterns/behaviors for R29.On 12/17/25 at 10:54 AM, Surveyor interviewed Regional Director C and asked if R29 has sleep behaviors documented in Electronic Health Record (EHR) and if staff are checking these behaviors. Regional Director C reported they could not find that staff were assessing sleep behaviors consistently every 2 hours as in the task to do list. Regional Director C also reported to Surveyor that a sleep assessment evaluation was only done in January of this year and never readdressed in April as suggested by pharmacy to discontinue Trazadone.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 6 residents (R), R25 and R15, observed for medication pass. The facility had 31 opportunities and 3 medication errors resulting in an 9.68% error rate. Registered Nurse (RN) L administered Atropine drops sublingual to R25 with unknown open date. RN E administered insulin pen without checking the expiration date and the correct physician order for R15.This is evidenced by:According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication.Example 1On 12/16/2025 at 8:33 AM, Surveyor observed RN L administer medications to R25. RN L administered Atropine drops sublingual. Surveyor observed Atropine bottle to have no open date label, so expiration was unknown resulting in a medication error. On 12/16/25 at 8:11 AM, Surveyor interviewed RN L and asked RN L what the correct process is for checking labels and expirations before administering medications. RN L looked at Atropine bottle and stated, You're right it does not have an open label. I should have discarded and gathered a new bottle before administering due to not knowing potency of medication and if it is expired or not. On 12/16/25 at 12:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of checking medications that are opened for open dates such as Atropine drops for R25. DON B reported that all nurses should be checking open date labels to prevent expired medications from being administered and this is considered a medication error. Example 2On 12/16/25 at 8:19 AM, Surveyor observed RN E administer 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 without checking physician order and open date of insulin pen, so expiration was unknown resulting in a medication error. On 12/16/25 at 8:32 AM, Surveyor interviewed RN E and asked RN E what the protocol is for checking insulin pens before administering and what do you do if there is no open date label on the pen. RN E reported to Surveyor that RN E usually looks to see the open date as insulin pens have to be discarded after 28 days, and RN E did not look before administering to R15. On 12/16/25 at 12:07 PM, Surveyor observed during medication reconciliation for medication administration that RN E documented in R15's Electronic Health Record (EHR), RN E gave Semiglee insulin 16 units to R15 instead of documenting 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin. Surveyor interviewed RN E and asked that RN E and Surveyor review R15's Medication Administration Record (MAR) together. Surveyor asked RN E if the insulin orders in R15's chart were accurate as RN E signed off on the Semiglee insulin order that RN E gave 16 units when the actual medication given was Lantus 16 units. RN E reported to Surveyor that RN E administered Lantus and signed out Semiglee insulin medication order. RN E reported R15's physician made a medication order a while ago to give Lantus in place of Semiglee until pharmacy can send Semiglee to the facility. RN reported the correct process is to discontinue the Semiglee insulin order to administer 16 units and place the Lantus order to administer 16 units into the MAR so that staff can sign out appropriately. RN E reported to Surveyor that it looks like it's a transcribing concern, and RN E should not have given the Lantus without a correct physician orderOn 12/16/25 at 12:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of signing out R15's Lantus insulin administered to the correct order in the MAR as RN signed out Semiglee insulin instead and that was not the medication given to R15. DON B reported that it sounds like there is an transcribing concern with R15's insulin orders and expectation would have been for whichever nurse on the floor receives a new medication order from the pharmacy that, the correct medication is entered in the MAR appropriately and then RN E should have then signed the Lantus out in a Lantus insulin order and not the Semiglee insulin on MAR. DON B reported that Semiglee order should be discontinued and correct medication placed in the MAR.

Based on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 6 residents (R), R15, observed for medication admonistration. Registered Nurse (RN) E administered 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 with no physician order for Lantus. This is evidenced by:According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication.On 12/16/25 at 8:19 AM, Surveyor observed RN E administer 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 without checking physician order and open date of insulin pen, so expiration was unknown resulting in a medication error. On 12/16/25 at 8:32 AM, Surveyor interviewed RN E and asked RN E what the protocol is for checking insulin pens before administering and what do you do if there is no open date label on the pen. RN E reported to Surveyor that RN E usually looks to see the open date as insulin pens have to be discarded after 28 days, and RN E did not look before administering to R15. On 12/16/25 at 12:07 PM, Surveyor observed during medication reconciliation for medication administration that RN E documented in R15's Electronic Health Record (EHR), RN E gave Semiglee insulin 16 units to R15 instead of documenting 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin. Surveyor interviewed RN E and asked that RN E and Surveyor review R15's Medication Administration Record (MAR) together. Surveyor asked RN E if the insulin orders in R15's chart were accurate as RN E signed off on the Semiglee insulin order that RN E gave 16 units when the actual medication given was Lantus 16 units. RN E reported to Surveyor that RN E administered Lantus and signed out in Semiglee insulin medication order. RN E reported R15's physician made a medication order a while ago to give Lantus in place of Semiglee until pharmacy can send Semiglee to the facility. RN reported the correct process is to discontinue the Semiglee insulin order to administer 16 units and place the Lantus order to administer 16 units into the MAR so that staff can sign out appropriately. RN E reported to Surveyor that it looks like it's a transcribing concern, and RN E should not have given the Lantus without a correct physician orderOn 12/16/25 at 12:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of signing out R15's Lantus insulin administered to the correct order in the MAR as RN signed out Semiglee insulin instead and that was not the medication given to R15. DON B reported that it sounds like there is an transcribing concern with R15's insulin orders and expectation would have been for whichever nurse on the floor receives a new medication order from the pharmacy that the correct medication is entered in the MAR appropriately and then RN E should have then signed the Lantus out in a Lantus insulin order and not the Semiglee insulin on MAR. DON B reported that Semiglee order should be discontinued and correct medication placed in the MAR.

Based on observation and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from residents' (R) medication supply. (R15 and R25) One insulin Lantus pen was not labeled with an open date or expiration of medication for R15 in 1 of 2 residents observed who received insulin. Atropine drops were not labeled with an open date or expiration of medication for R25 in 1 of 1 resident observed who received Atropine. Findings include: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Example 1On 12/16/25 at 8:19 AM, Surveyor observed Registered Nurse (RN) E administer 16 units of insulin glargine 100 UNT/ML Pen Injector [Lantus] insulin to R15 with no open date label on the insulin pen.On 12/16/25 at 8:32 AM, Surveyor interviewed RN E and asked RN E what the protocol is for labeling insulin pens, checking insulin pens before administering and what do you do if there is no open date label on the pen. RN E reported to Surveyor that RN E usually looks to see the open date as insulin pens must be discarded after 28 days, and RN E did not look before administering to R15. RN E reported that when pharmacy sends medications in, it's the nurse's job to appropriately label the insulin pen once opened with a sticker. On 12/16/25 at 12:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of labeling insulin pens as R15's insulin pen did not have an open date label before RN E administered R15's insulin. DON B expectation is that all staff are to follow facility policy and label any medication that is opened with the open date. If it is an insulin pen, the pens need to have an open date label along with expiration date, so all staff know when to discard. DON B reported that RN E should have discarded the insulin pen and opened a new one. Example 2 On 12/16/2025 at 8:33 AM, Surveyor observed RN L administer medications to R25. RN L administered Atropine drops sublingual. Surveyor observed Atropine bottle to have no open date label, so expiration was unknown.On 12/16/25 at 8:11 AM, Surveyor interviewed RN L and asked RN L what the correct process is for checking labels and expirations before administering medications. RN L looked at Atropine bottle and stated, You're right it does not have an open label. I should have discarded and gathered a new bottle before administering due to not knowing potency of medication and if it is expired or not. On 12/16/25 at 12:11 PM, Surveyor interviewed DON B and asked expectation of checking medications that are opened for open dates such as Atropine drops for R25. DON B reported that all nurses should be checking open date labels to prevent expired medications from being administered.

Based on observation, interview and record review, the facility failed to ensure standards of practice were followed for verification of gastrostomy placement before medication administration. The facility also failed to provide proper infection control measures by performing hand hygiene during medication administration and ensuring the enteral formula used to provide nutrition was changed every 24 hours for 1 of 1 resident (R) reviewed for tube feeding. (R34) This is evidenced by: Facility policy titled, Medication Administration 7.10 Enteral Tubes dated 05/23, states in part, - .8. Verify tube placement per facility protocol. -9. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100mL . R34 was admitted on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, dysarthria ., dysphagia following nontraumatic intracerebral hemorrhage, encounter for attention to gastrostomy, apraxia, dysphagia oral phase. R34's Minimum Data Set (MDS) assessment, dated 07/08/24, identified on admission that R34 could not complete a Brief Interview for Mental Status (BIMS) for cognition deficiencies due to R34 being non-verbal in communication. Surveyor reviewed R34's care plan, dated 07/08/24: -R34 receives bolus tube feedings if R34 does not eat 75% of meals per day. On 09/10/24 at 10:31 AM, Surveyor observed Licensed Practical Nurse (LPN) D prepare R34's medications. On 09/10/24 at 10:34 AM, Surveyor observed LPN D don gloves. LPN D began flushing R34's G-tube with 30 cc of tap water. LPN D then administered medication via R34's G-tube. LPN D flushed R34's tube with another 30 cc of tap water. Surveyor did not observe LPN D check Gastric Residual Volume (GRV) prior to administration of flushes and medication. Surveyor interviewed Director of Nursing (DON) B and asked DON B what the expectation is for assessing GRV before flushing or administering medications via G-tube. DON B indicated that all staff are to assess GRV by pulling back syringe to check for gastric contents. Surveyor indicated to DON B that LPN D did not check GRV before flushing R34's G-tube and administering medications. DON B indicated that LPN D should have checked GRV. 48793 Example 2 Surveyor reviewed physician orders which include: .On 08/29/24, If resident did not eat 25-50% of all meals today give bolus feeding of Promote with Fiber 1.0 calorie total 360ml via PEG tube at bedtime for diet administer 60ml of water before and after each tube feeding . On 09/10/24 at 10:36 AM, Surveyor observed Promote with Fiber container sitting on R34's bedside table. Surveyor observed a label, dated 09/03/24, and about 100ml of fiber formula left in used promote fiber container. On 09/11/24 at 11:32 AM, Surveyor interviewed DON B and asked what the expectation is for changing formula feeding container for R34. DON B indicated formula that is used for tube feedings, once opened, should be discarded within 24 hours. Surveyor indicated to DON B that formula was observed sitting on R34's bedside dated 09/03/24. DON B indicated that R34's formula sitting on the bedside table should be properly disposed of and changed every 24 hours when in use.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 35 medication opportunities, resulting in an error rate of 5.71%. This affected 2 out of 6 residents (R) (R34 and R240) observed for medication administration. Licensed Practical Nurse (LPN) D did not follow physician orders for R34's heparin injection and administered heparin via incorrect route. R34 did not receive 2 units of insulin per sliding scale per physicians' orders. Findings include: The facility's policy entitled Medication Administration - subcutaneous, dated 01/23 states in part, Equipment .Safety syringe and sterile safety needle of appropriate gauge .13. Hold needle with bevel side up and insert needle at a 45-degree angle to the skin surface. Example 1 Surveyor reviewed R240's physician orders, dated 09/06/24, which state in part: - Heparin Sodium 50,000/10ml (5,000/ml) Inject 1ml subcutaneous every 12 hours. On 09/10/24 at 9:23 AM, Surveyor observed LPN D draw Heparin 50,000/10ml (5,000/ml) 1 ml from a multi-dose vial into a [NAME] point 1 inch syringe. LPN D called for Director of Nursing (DON) B to verify dose. DON B verified Heparin dose observing the syringe to have a 1 needle on the tip of the syringe. Surveyor heard DON B state to LPN D, Remember to only go halfway in because we don't have any smaller needles. LPN D stated to DON B, I know I never go all the way in, only about halfway. Surveyor observed LPN D administer the Heparin 1ml at a 90-degree angle submersing the whole 1 needle directly into R240's abdomen. Surveyor did not observe LPN D administer the Heparin 1ml subcutaneously at a 45-degree angle as ordered. On 09/10/24 at 3:22 PM, Surveyor interviewed DON B and asked DON B about the specifications of the [NAME] Point syringes and was it appropriate for LPN D to administer the full 1 needle into R240's abdomen. DON B indicated the facility only has the [NAME] point 1 needles at this time. DON B indicated that DON B usually only goes into R240's abdomen 1/4- 1/2 deep. DON B indicated that LPN D should not have given the Heparin injection into R240's abdomen the full 1. DON B indicated that would not be considered a subcutaneous injection. Example 2 Surveyor reviewed R34's physician orders which state in part: - Insulin Glargine Subcutaneous Solution 100 unit/ml, inject 25 unit subcutaneously in the morning and inject 20 unit subcutaneously in the evening dated 08/05/24. -Insulin Aspart Injection Solution 100 unit/ml, inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 3 units; 251 - 300 = 5 units; 301 - 350 = 7 units; 351 - 400 = 10 units >400 give 12 units and call MD and recheck BS in 2 hours., subcutaneously as needed dated 07/01/24. On 09/10/24 at 10:28 AM, Surveyor observed LPN D administer Insulin Glargine 25 units subcutaneously to R34. Surveyor did not observe LPN D administer R34's sliding scale insulin. R34's blood sugar result was 151 when checked. R34 should have received 2 units of Insulin Aspart per the sliding scale orders. On 09/10/24 at 1:55 PM, Surveyor interviewed LPN D and asked why LPN D did not give R34's sliding scale insulin during medication administration. LPN D looked in R34's Electronic Health Record (EHR) and LPN D indicated that LPN D was unaware that R34 had a sliding scale. LPN D indicated that since the sliding scale is as needed LPN D didn't think that R34 needed the sliding scale insulin. On 09/10/24 at 2:51 PM, Surveyor interviewed DON B and asked why LPN D did not give R34's sliding scale insulin during medication administration. DON B indicated that LPN D should have given the sliding scale insulin but the order in the EHR was not entered into the system the right way. DON B indicated that the sliding scale was not linked to the scheduled insulin given throughout the day for R34. DON B indicated that the order was transcribed incorrectly in the EHR. DON B indicated the order is entered correctly now.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when changing gloves during resident cares and procedures for 3 of 4 resident (R) care observations (R29, R240, and R34). Staff did not wear proper personal protective equipment (PPE) when caring for a resident on Enhanced Barrier Precautions. (R34) Findings include: Facility policy and procedure entitled, Hand Hygiene, dated 11/02/22, stated in part: .2. Hand hygiene is indicated and will be performed .Between resident contacts, after handling contaminated objects, before applying and after removing PPE, including gloves, before preparing or handling medications, and after assistance with personal body functions (elimination, hair grooming, smoking, etc.) . 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Example 1 On 09/10/24 at 7:55 AM, Surveyor observed Registered Nurse (RN) C provide wound care for R29. Surveyor noted a sign on the outside of R29's door that stated Contact Precautions. RN C used hand sanitizer and donned a gown and gloves before entering the room. After preparing supplies at the bedside, RN C assisted R29 to roll to the left side. RN C pulled down R29's pants and unfastened the brief to expose R29's bottom. RN C removed the old border foam dressing and packing from the wound on R29's right buttocks. RN C removed gloves, threw them in a plastic bag at the bedside, and put on a new pair of gloves. RN C did not wash hands or use hand sanitizer before putting on the clean gloves. RN C wet a gauze pad with saline and washed the wound area. RN C wet a sterile cotton swab and cleansed inside the wound. RN C used a cotton swab to pick up a gauze strip and packed the strip into the wound. RN C covered the wound packing with a border foam dressing. RN C removed gloves and threw them in the plastic bag. RN C put on clean gloves. RN C did not wash hands or use hand sanitizer before putting on the clean gloves. RN C assisted R29 to roll back onto back. RN C replaced the tape that was securing R29's Foley catheter per R29's request for comfort. RN C assisted R29 to fasten incontinent brief and pull up pants. RN C removed the gloves and put on clean gloves without using hand sanitizer or washing hands. RN C put away dressing supplies and disposed of trash. RN C removed gown and gloves in R29's room and washed hands with soap and water. Immediately following observation, Surveyor interviewed RN C and asked what the facility infection control practice was when changing gloves during wound care procedures. RN stated they probably should have washed hands or used hand sanitizer, but they forgot to do this today. On 09/11/24 at 9:51 AM, Surveyor interviewed Director of Nursing (DON) B and explained the observation of RN C providing wound care for R29. Surveyor stated RN C did not perform hand hygiene when changing gloves during the procedure. Surveyor asked DON B if RN C followed the proper procedure for infection control and hand hygiene. DON B stated RN C should have washed hands or used hand sanitizer each time they changed gloves. 48793 Example 2 On 09/10/24 at 9:31 AM, Surveyor observed Certified Nursing Assistant (CNA) E enter R240's room and did not sanitize hands. Surveyor observed CNA E have a black wrist brace on right wrist. CNA E touched EZ Stand lift to hook lift sling to machine and tucked sling behind R240. CNA E transferred R240 into bed. CNA E grabbed R240's legs and feet to swing unto bed with bare hands. CNA E then grabbed chuck underneath R240 and boosted R240 up in bed. CNA E covered R240 with blankets and lowered the bed to the floor. Surveyor observed CNA E walk to the sink and wash the tips of CNA E's fingers on the right hand and then dry hands and walked out. CNA E entered with EZ-stand into R13's room without performing proper hand hygiene. CNA E started placing sling underneath R13 and then transferred R13 to the bathroom. CNA E pulled R13's pants down and then exited R13's room applying hand sanitizer to the tips of CNA E's fingers on both hands. Surveyor did not observe full hand hygiene to sanitize CNA E's full hands. On 09/10/24 at 10:01 AM, Surveyor observed CNA F and CNA E enter R240's room. CNA F and CNA E sanitized hands, gloved, then began dressing R240's footwear to transfer out of bed to the toilet. CNA F and CNA E transferred R240 to the bathroom. Surveyor observed CNA E doff gloves and use sanitizer to sanitize tips of fingers on the right hand and then CNA E exited R240's room. Surveyor did not observe CNA E perform adequate hand hygiene. On 09/10/24 at 10:41 AM, Surveyor interviewed CNA E and asked CNA E about CNA E's right wrist brace and hand hygiene practices. CNA E indicated that CNA E injured wrist at work and tries CNA E's best to perform hand hygiene. CNA E indicated it is tough to find gloves that cover the brace completely and for now CNA E tries to sanitize the tips of the right fingers and sometimes washes hands with brace on. CNA E indicated that CNA E was going to try and find longer gloves to cover the brace. Surveyor indicated to CNA E that Surveyor observed CNA E not perform hand hygiene when entering R240 and R13's rooms. CNA E indicated that CNA E should have at least sanitized in between rooms. On 09/10/24 at 11:32 AM, Surveyor interviewed DON B and asked what the expectation is for CNA E wearing wrist brace and infection control practices. DON B indicated that CNA E should be wearing gloves over wrist when providing cares and sanitizing and washing hands thoroughly. Surveyor indicated to DON B that Surveyor observed CNA E did not sanitize hands between resident rooms, and only washed fingertips of the right hand. DON B indicated that CNA E should have washed hands or sanitized hands before/after providing care to residents and entering and exiting residents' rooms. 51095 Example 3 Surveyor reviewed facility policy titled, Enhanced Barrier Precautions (EBP), dated 3/35/2024 reviewed/revised on 08/08/2024, which stated in part: .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs): Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. -4. High-contact resident care activities include: .g. Device care or use . feeding tubes . On 09/10/24 at 10:34 AM, Surveyor observed Licensed Practical Nurse (LPN) D enter R34's EBP room without donning personal protective equipment (PPE) for EBP. LPN D then applied gloves and injected insulin and removed gloves. On 09/10/24 at 10:39 AM, Surveyor observed LPN D take R34's blood pressure without practicing hand hygiene or donning PPE. On 09/10/24 at 10:41 AM, Surveyor observed LPN D don gloves, and then flush and administer medication into R34's G-tube. Surveyor did not observe LPN D perform hand hygiene or don PPE before flushing and administering medications through R34's G-tube. On 09/10/24 at 10:44 AM, Surveyor observed LPN D perform G-tube site care without changing gloves or performing hand hygiene. LPN D removed soiled gauze dressing from G-tube site, wiped R34's skin area surrounding g-tube with alcohol pad several times, then sprayed wound cleanser on gauze and wiped skin area again. LPN D placed new split gauze at G-tube site and removed gloves. Surveyor did not observe LPN D perform hand hygiene or don PPE before or during G-tube care. On 09/10/24 at 10:48 AM, Surveyor observed LPN D perform a second blood pressure to R34 without donning any PPE. On 09/10/24 at 10:51 AM, Surveyor observed LPN D exit R34's room and go to the medication cart to prep R34's oral medications. Surveyor did not observe LPN D perform hand hygiene. On 09/10/24 at 12:40 PM, Surveyor interviewed LPN D and asked what R34 is on EBP for. LPN D indicated that R34 is on EBP for tube feeding. LPN D indicated to Surveyor that LPN D did not wear PPE like LPN D should have. Surveyor asked LPN D what the expectation is for hand hygiene when administering medications via R34's G-tube. LPN D indicated that LPN D should wear gloves and perform hand hygiene before and after donning and doffing gloves. On 09/10/24 at 2:51 PM, Surveyor interviewed DON B and asked DON B what the expectation was for hand hygiene during medication administration and wearing PPE during cares for R34's G-tube. DON B indicated that nurses should wash or sanitize hands between medication administration of G-tube and don PPE when performing cares of R34's G-tube.

Based on record review and interviews, the facility did not ensure a resident's (R) advanced directives for code status were implemented according to resident wishes for 1 of 14 residents (R) 35 reviewed for advanced directives. R35 had a Do Not Resuscitate (DNR) order signed by R35 on [DATE] and signed by the physician on [DATE]. On [DATE], R35 became unresponsive requiring the invoking of R35's code status. Staff was unable to find the advanced directives and code status for R35 and performed cardiopulmonary resuscitation (CPR). Despite R35 indicating the intent to not receive CPR, R35 was provided CPR on [DATE]. R35 did not survive the code status and was pronounced deceased following the event. The facility's failure to follow a resident's advanced directive created a finding of immediate jeopardy that began on [DATE] at 6:30 p.m. Nursing Home Administrator (NHA) was notified of the immediate jeopardy on [DATE] at 10:45 a.m. The immediate jeopardy was not removed when the surveyors left the facility at 4:30 p.m. on [DATE]. Findings include: The facility had a policy referencing how to do CPR, but no policy on filing advanced directive paperwork. R35 was admitted to the facility on [DATE] with diagnoses of right pubic fracture, depression, low back pain, cognitive communication deficit, subdural hematoma, type 2 diabetes, severe retinopathy, and hypertension. R35 was receiving therapy with a goal to return home. R35 had a Brief Interview for Mental Status score of 13 which indicated intact cognition. R35 signed the DNR wishes on the day of admission. The facility process was to check the electronic medication administration record (eMAR), the binder at the nurses' station, or check in the electronic chart under miscellaneous for advanced directives. Surveyor reviewed R35's physician's orders signed on [DATE] and the [DATE] eMAR that identified there were no orders transcribed regarding code status. Surveyor reviewed progress note dated [DATE] at 6:30 p.m. that stated R35 was talking, propelling self in wheelchair when Registered Nurse (RN) E observed R35 slump over. On-call doctor was updated, and order received to send R35 to the emergency room (ER). Other staff began cardiopulmonary resuscitation (CPR) while emergency medical system (EMS) was notified. EMS arrived and took over. CPR was unsuccessful and R35 was pronounced dead on [DATE] at 7:08 p.m. On [DATE] at 1:02 p.m., Surveyor interviewed RN E who was the nurse on duty when the event occurred. RN E stated that R35 had some increased confusion and asked the medical doctor (MD) I to check on R35. RN E stated that MD I thought something was going on with R35 but was not sure, so MD I ordered labs for morning. RN E checked R35's vital signs and they were normal earlier that day. R35 came to dining room for dinner and only had broth and crackers then asked staff to push R35 out in the hallway which is usual. R35 started to propel to the bedroom when RN E noticed R35's hand was hanging down by the wheelchair spokes. RN E approached R35 and witnessed R35's eyes rolled back, and body slumped to the right. RN E took R35 via wheelchair to R35's room. RN E stated that another nurse and CNA ran for the crash cart. RN E grabbed the AED and called the on-call who said to send R35 to the hospital. RN E asked the on-call what the code status is for R35 since RN E could not find it in the electronic record. RN E stated that the on-call doctor said R35 was a full code in their records. When EMS arrived, R35 was intubated, used the [NAME] machine (machine that provides chest compressions), and worked on R35 for 35 minutes with no heart rate. RN E said the code status is usually on the face sheet or under the miscellaneous tab, but it was not in the computer, so RN E erred on the side of caution. On [DATE] at 1:12 p.m., Surveyor interviewed Director of Nursing (DON) B and RN E. RN E could not find the code status for R35 on the computer and later said that R35's advanced directives note DNR but aggressive treatment. Surveyor's interview with DON B indicated that the advanced directive was scanned into the system, RN E could not find it and panicked and called the on call. When Surveyor reviewed the form with DON B, that stated on the heading above aggressive treatment it was stated Treatment options when the Patient/Resident has pulse and/or is breathing, DON B stated R35 had no pulse and was not breathing therefore R35 should not have received CPR. On [DATE] at 10:45 a.m., Surveyor interviewed NHA and DON B via a telephone call. Surveyor asked what had gone wrong that R35's advanced directive wishes did not show up in the Electronic Health Record (EHR). NHA A indicated that the admitting nurse did not follow through with entering the orders on admission. Surveyor asked whose responsibility it was to enter code status on admission and whenever there was a change. NHA A indicated that the nurse admitting is responsible, and whatever nurse is working and is made aware of a change in the code status is responsible for entering the updated order, that then will show up in the eMAR. DON B stated that all residents' records for advanced directives are scanned into the Miscellaneous Section of the EHR. Surveyor asked if R35's advanced directive documents were in the miscellaneous tab at the time of this incident. DON B indicated that they were there, but sometimes are hard to find. DON B indicated that RN E panicked when she could not locate them and called the on-call doctor. On [DATE] at 1:40 p.m., Surveyor interviewed RN D, who was the nurse that admitted R35. Surveyor asked RN D if she recalled R35 and some of the events for R35's admission. RN D indicated being aware of the situation and feels just sick about it. Surveyor asked what education was provided to her about entering code status on admission. RN D indicated she had been educated to enter the order so it would be on the eMAR, as well as to put a copy of the code status in the binder at the nurses' station. Surveyor asked if RN D had done so for R35's admission. RN D indicated that she had not. For some reason she did not follow through. RN D stated, It was an innocent mistake. As evidenced above, facility staff initially did not know what R35's advance directives were. Staff, at some point, either before or at the direction of the on-call doctor, began CPR. Paramedics were required to begin CPR because there was no legal document presented indicating R1 did not want to be resuscitated. On [DATE] at 12:40 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) F and asked what LPN F would do if a resident became unresponsive. LPN F said she would check the code status on the eMAR or on the electronic record under the miscellaneous tab/advanced directives. LPN F said if a resident was a full code, LPN F would then call a code blue, grab the crash cart, the AED, contact the on-call doctor for order to send resident to the ER, and then start CPR. On [DATE] at 12:43 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) G and asked what CNA G would do if a resident went unconscious. CNA G would call for a nurse over the walkie talkie ASAP. CNA G added that CNAs are not required to be CPR certified, and only nurses are allowed to perform CPR. On [DATE] at 12:50 p.m., Surveyor interviewed RN H and asked what RN H would do for an unresponsive resident. RN H would call the code, grab the crash cart and the board, check advanced directives, instruct someone to call 911, grab the AED. RN H added that CNAs are not allowed to do CPR and advanced directives are found in the eMAR and in a binder at the nurse's station. On [DATE] at 3:34 p.m., Surveyor called Facility Medical Director (FMD) J and asked what R35 would have gone through if CPR would have been successful. FMD J stated that R35 would have had the potential to be put on a ventilator (life support), placed on medications to sustain life, and if found out later R35 was a DNR, they would withdraw the life support. If R35 were to survive it, R35 would have the potential for pain from CPR with a possibility of broken ribs. Generally, people on life support are heavily sedated to not fight the system, so R35 may not even be aware. There would be blood work done, positioning, and tape on R35's face from the breathing tube. According to Five Possible Side Effects of CPR, You Should Know, The methods used in Cardiopulmonary Resuscitation can have adverse effects such as the following: 1. Aspiration & Vomiting: The most frequent occurrence during CPR, vomiting can present a danger to the cardiac arrest victim. Since the cardiac arrest victim is unconscious, he cannot clear the vomit from his mouth. If not cleared, the victim is likely to aspirate (inhale) it into his lungs, blocking the airway and leading to possible infection. 2. Broken Ribs Bone: A rib fracture is the most common complication of CPR because the force of chest compressions is likely to break ribs. Other chest injury related to chest compressions are sternal fracture and other uncommon complication like lung contusion, pneumothorax, and hemothorax. In the elderly, this is significantly more common due to the brittleness and weakness of their bones. Broken ribs present danger because a broken rib could puncture or lacerate (cut) a lung, the spleen, or the liver. They are also very painful. The frequency of rib fractures associated with out of hospital cardiopulmonary resuscitation is underestimated by conventional chest x-ray. 3. Internal Brain Injuries: Since CPR leaves the brain receiving 5% less oxygen than normal, brain damage is possible. Brain damage occurs within 4 to 6 minutes from the time the brain is deprived of oxygen, and after 10 minutes, it definitely occurs. This can lead to long-term health complications. 4. Abdominal Distension: As a result of air being forced into the lungs, the abdomen of the cardiac arrest patient usually becomes distended (bloated) and full of air during CPR, leading to compression of the lungs (making ventilation more difficult) and an increased chance of vomiting. 5. Aspiration Pneumonia: The result of vomit and foreign objects (like a person's own teeth) being inhaled into the lungs can lead to aspiration pneumonia. This can be very dangerous to a victim's health and could complicate recovery, or even be fatal, even if the cardiac arrest victim does survive CPR. Overall, all of these side effects mean that if a person survives CPR, their long-term health could suffer and be alive. But their overall health and quality of life may be significantly affected. Additionally, the psychological ramifications of a near-death experience can substantially affect a survivor, leading to anxiety, stress, and depression, among other psychological conditions. https://www.mycprcertificationonline.com/blog/five-possible-cpr-side-effects-you-should-know/ According to a National Public Radio article, For many, a 'natural death' may be preferable to enduring CPR, Chest compressions are often physically, literally harmful. Fractured or cracked ribs are the most common complication, wrote the original Hopkins researchers, but the procedure can also cause pulmonary hemorrhage, liver lacerations, and broken sternums. If your heart is resuscitated, you must contend with the potential injuries. A rare but particularly awful effect of CPR is called CPR-induced consciousness: chest compressions circulate enough blood to the brain to awaken the patient during cardiac arrest, who may then experience ribs popping, needles entering their skin, a breathing tube passing through their larynx. The traumatic nature of CPR may be why as many as half of patients who survive wish they hadn't received it, even though they lived. It's not just a matter of life or death, if you survive, but quality of life. The injuries sustained from the resuscitation can sometimes mean a patient will never return to their previous selves. Two studies found that only ,d+[DATE]% of older patients who survive CPR were able to function independently; others found somewhat better rates of recovery. An even bigger quality of life problem is brain injury. When cardiac activity stops, the brain begins to die within minutes, while the rest of the body takes longer. Doctors are often able to restart a heart only to find that the brain has died . About 30% of survivors of in-hospital cardiac arrest will have significant neurologic disability. Again, older patients fare worse. Only 2% of those over 85 who suffer cardiac arrest survive without significant brain damage. https://www.npr.org/sections/health-shots/[DATE]/1177914622/a-natural-death-may-be-preferable-for-many-than-enduring-cpr The facility's failure to ensure R35's advanced directive decision to not receive CPR was followed and not following the facility process on filing advanced directive paperwork created a situation of immediate jeopardy that began on [DATE]. As of [DATE] at 4:30 p.m., the facility did not complete staff education or revise the policy and procedure to include how to file the advanced directive information. The immediate jeopardy was not removed at the time of exit.

Based on observation and interview, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection. This occurred for observation of cares for 1 of 2 residents (R) R4. Staff did not perform proper hand hygiene during observation of cares for R4. This is evidenced by: Surveyor reviewed the facility policy entitled Hand Hygiene, dated 11/02/22, which states either soap and water or alcohol-based hand rub will used when hands are visibly dirty, before and after handling clean or soiled dressings, linens, etc., after handling items potentially contaminated with blood, body fluids, secretions, or excretions. On 09/13/23 at 10:37 AM, Surveyor observed Certified Nursing Assistant (CNA) C conducted the following during cares on R4 that included incontinence care: CNA C obtained wash basin, and supplies, washed hands and donned gloves. CNA C conducted frontal peri care switching areas on cloth using downward motions. CNA C rinsed with different cloth and dried area and removed gloves. CNA C did not perform hand hygiene at this time. CNA C obtained a container of powder, donned a new pair of gloves, and applied powder to R4's peri area. CNA C did not perform hand hygiene prior to applying new gloves. CNA C removed gloves, obtained clean incontinent product, then donned new gloves. CNA C did not perform hand hygiene. CNA C washed R4's back side including buttocks and rectal area using a clean washcloth and placed the clean incontinent product. CNA C removed gloves without performing hand hygiene. CNA C then held R4's straw for R4 to take a drink from the water jug. CNA C placed the dirty washcloths in a plastic bag, put away the water basin, removed gloves, washed hands, and exited the room. On 09/13/23 at 10:59 AM, Surveyor interviewed CNA C regarding expectation of when to wash hands. CNA C stated during cares, before and after removing gloves, and after going to bathroom. On 09/14/23 at 1:36 PM, Surveyor interviewed DON B regarding observation of lack of handwashing after completing incontinence care. DON B stated the facility has been doing a lot of extra training on hand hygiene and monitoring due to new staff. DON B stated the expectation would be to wash hands before and after cares, after removing gloves and when hands are dirty.

Based on interviews and record review, the facility did not ensure residents were free of falls for 1 out of 4 sampled residents reviewed for falls. Resident #1 sustained a fall which resulted in a right ankle fracture when staff transferred Resident #1 onto the toilet without proper footwear and then left Resident #1 unattended when staff had knowledge of the recent change in mental status and attempts to self transfer. This is evidenced by: On 07/23/13, Surveyor # requested and reviewed the facility policy titled "Falls Management Clinical Guidelines." The policy read "The interdisciplinary team evaluates the fall prevention plan of care for residents 'at risk' for falls...Following the completion of the Minimum Data Set MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA (Care Area Assessment) guidelines. The plan of care is updated, if indicated, to further minimize the risk of falls..." Resident #1 was admitted to the facility on [DATE] for care and rehabilitation following a stroke. Review of Resident #1's admission MDS (Minimum Data Set), completed on 05/30/13, noted the following: ~was sometimes able to make self understood; ~rarely/never able to understand others; ~was severely impaired for daily decision making; ~required extensive assist of two or more staff for bed mobility, transfers, toilet use, and hygiene; ~required extensive assist of 1 staff for dressing and eating; ~had a history of [REDACTED]. ~impaired balance with standing, surface to surface transfers, and moving on and off toilet. The facility completed a fall risk assessment for Resident #1 on 05/17/13 and noted Resident #1 was at risk for falls due to intermittent confusion, required assistance for elimination, impaired balance/gait, potential medication side effects, and medical diagnoses. The care plan for Resident #1 titled "At risk for falls..." initiated on 05/29/13, noted interventions including footwear to prevent slipping-gripper socks for assisted transfers. Resident #1 also had a care plan titled "Pressure ulcer..." that included an intervention which read heel boots for redistribution of pressure to be worn at all times except for cares and transfers. Resident #1 had an avoidable pressure ulcer on the right heel that developed on 05/24/13, which was treated with pressure redistribution boots on both feet. The redistribution boots are not to be worn during transfers due to increased risk of slipping and no traction or support on the soles of the feet. Review of Resident #1's nurse's note, dated 6/28/13, stated Resident #1 had fallen after being left unsupervised in the bathroom. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 returned to the facility on [DATE]. On 07/23/13 at 1:15 p.m., Surveyor # interviewed RN-D (Registered Nurse) regarding Resident #1's fall. RN-D stated on 06/28/13, at approximately 1:00 p.m., she observed Resident #1 leaning forward in the wheelchair attempting a self transfer. RN-D noted Resident #1 to be confused and assisted Resident #1 to the bathroom with the help of CNA-C. Note: Nursing note, dated 6/28/13 at 14:38 (2:38 p.m.) stated, "Resident was found in her bathroom lying on floor. This was an unwitnessed fall." RN-D stated to Surveyor # she assessed Resident #1 for any fracture while Resident #1 was on the bathroom floor. RN-D stated she and two CNAs assisted Resident #1 into bed then removed the redistribution boot and noted the right ankle was displaced. RN-D stated Resident #1 also complained of right ankle pain. RN-D stated Resident #1 had on the redistribution boots when found on the bathroom floor. On 07/23/13 at 2:40 p.m., Surveyor # interviewed CNA-B regarding Resident #1's fall. CNA-B stated she was the first nursing staff on the scene of Resident #1's fall after the ancillary staff informed her of Resident #1's condition. CNA-B confirmed Resident #1 had both redistribution boots on. CNA-B stated Resident #1 needed the gripper socks on prior to transfers because the redistribution boots were very slippery and she had no traction during transfers. On 07/24/13 at 1:45 p.m., Surveyor # interviewed CNA-C regarding Resident #1's fall of 06/28/13. CNA-C stated she had not removed the redistribution boots prior to or after the transfer onto the toilet. CNA-C stated she was aware Resident #1 was not her usual self and was concerned Resident #1 may attempt a self transfer. CNA-C stated she gave Resident #1 the call light with reminders to use the call light and not to transfer self. After RN-D and CNA-C assisted Resident #1 to the bathroom, CNA-C removed the wheelchair from the bathroom to reduce the temptation for Resident #1 to self transfer. CNA-C stated she should have stayed with Resident #1 because Resident #1 was confused and not herself. CNA-C stated she did continue with the daily duties of answering call lights and helping residents lie down. CNA-C stated she was aware the care plan stated to have on gripper socks and not the redistribution boots for transfers. CNA-C stated she was aware of Resident #1's change in mental status because she observed RN-D assess Resident #1 for mental status. CNA-C also stated she was told by RN-D that Resident #1 had an attempt to self transfer earlier that afternoon. On 07/23/13, Surveyor # requested and reviewed the facility's fall investigation for Resident #1. The investigation had information that was not supported by the Surveyor's investigation. The investigation discrepancies were: ~the investigation stated Resident #1 was bare foot; ~the investigation stated Resident #1 was found on the floor by the CNA who placed on toilet; ~the investigation stated Resident #1 was at her baseline when assisted to the toilet. On 7/23/13, Surveyor # spoke with the NHA (Nursing Home Administrator). The NHA indicated the information regarding the pressure redistribution boots did not come out in the facility investigation.