Every finding on record at Heritage Healthcare of Hammond

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% for 1 (#70) of 11 residents observed during medication administration. A total of 52 opportunities were observed with 20 medication errors, which resulted in a medication error rate of 38.46%. Findings: Review of the facility's policy titled Medication Administration with an effective date of 10/04/2024 revealed the following, in part:Medication Administration: Prior to administration, the Nursing staff member administering the medication shall ensure that the following steps are accomplished.d. Verify the medication is being administered at the proper time Medication Administration Times:Medication should be administered within 60 minutes before or after the scheduled time. Review of Resident #70's Clinical Record revealed Resident #70 was admitted to the facility on [DATE] and had diagnoses, which included Essential (Primary) Hypertension; Hypertensive Heart Disease Without Heart Failure; Hyperlipidemia; Chronic Kidney Disease; Heart Failure; Atrial Fibrillation. Review of Resident #70's Physician Orders and MAR for 04/2026 revealed the following medications were scheduled for administration at 8:00 a.m.: Amiodarone HCl Oral Tablet 200 MG. Give 1 tablet by mouth one time a day.Amlodipine Besylate Oral Tablet 10 MG. Give 1 tablet by mouth one time a day.Clopidogrel Bisulfate Oral Tablet 75 MG. Give 1 tablet by mouth one time a day.Lovenox Injection Solution Prefilled Syringe 40 MG/0.4ML. Inject 0.4 ml subcutaneously one time a day.Furosemide Oral Tablet 20 MG. Give 1 tablet by mouth one time a day.Potassium Chloride ER Oral Tablet Extended Release 10 MEQ. Give 1 tablet by mouth one time a day.Pantoprazole Sodium Oral Tablet Delayed Release 40 MG. Give 1 tablet by mouth one time a day.Sitagliptin Oral Tablet 100 MG. Give 1 tablet by mouth one time a day.Rosuvastatin Calcium Oral Tablet 10 MG. Give 1 tablet by mouth one time a day.Zoloft Oral Tablet 50 MG. Give 1 tablet by mouth one time a day.Suzetrigine Oral Tablet 50 MG. Give 1 tablet by mouth two times a day.Precose Oral Tablet 25 MG. Give 1 tablet by mouth with meals.Linaclotide Oral Capsule 72 MCG. Give 1 capsule by mouth one time a day.Aspirin EC Oral Tablet Delayed Release 81 MG. Give 1 tablet by mouth one time a day.Fish Oil Oral Capsule 1000 MG. Give 2 capsule by mouth one time a day.Ferrous Sulfate Oral Tablet 325 MG. Give 1 tablet by mouth one time a day.Cholecalciferol Oral Tablet 125 MCG. Give 1 tablet by mouth one time a day.Oyster Shell Calcium/D Oral Tablet 250-3.125 MG-MCG. Give 1 tablet by mouth one time a day. On 04/13/2026 at 9:39 a.m., an observation was made of S3ADON preparing to pass the above listed medications to Resident #70. S3ADON stated the medications administered to Resident #70 were scheduled to be administered at 8:00 a.m. When she went to find Resident #70 to administer the medications, Resident #70 had left the facility for a Doctor's appointment. On 04/13/2026 at 10:06 a.m., an interview was conducted with S3ADON. S3ADON stated if a resident had a medication scheduled for 8:00 a.m., the medication should be administered between 7:00 a.m. to 9:00 a.m. S3ADON confirmed she attempted to pass the above listed medications to Resident #70 after 9:00 a.m., but Resident #70 was not in the facility. She stated the oncoming nurse would administer the medications when Resident #70 returned to the facility. On 04/13/2026 at 4:12 p.m., an interview was conducted with S9LPN. S9LPN confirmed she did not administer Resident #70's daily medications when Resident #70 returned from her doctor's appointment and should have. She stated Resident #70 returned from her Doctor's appointment at 1:30 p.m. On 04/15/2026 at 11:15 a.m., an interview was conducted with S2DON. S2DON stated medications should be given as ordered by the physician.

Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#29) of 31 residents reviewed during the initial pool. Findings: Review of the facility's policy titled Resident Call Light System Policy and Procedure with an effective date of 09/14/2022, revealed the following, in part:Purpose:1. To provide a communication system with audible or visual signals to allow residents to call for staff assistance from their bedside . Procedure:6. When providing care to residents, be sure to position the call light conventionally within reach for the resident to use. Review of Resident #29's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Generalized Muscle Weakness, Difficulty In Walking, and Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #29's Quarterly MDS with an ARD of 02/25/2026, revealed she had a BIMS of 11, which indicated she was moderately cognitively impaired. Further review revealed Resident #29 was always incontinent of bowel and bladder and required substantial/maximal assistance for toileting hygiene. Review of Resident #29's current Care Plan revealed the resident was at risk for falls. Interventions included to be sure the resident's call light is within reach. On 04/12/2026 at 10:53 a.m., an observation was made of Resident #29 in her room. She was lying in bed with her soft touch call light on the nightstand out of reach. An interview was conducted at this time and Resident #29 stated she needed to be changed. She stated she wanted to call the CNA for assistance, but her call light was moved out of reach sometime during the night. She stated she used her call light often and confirmed she could not reach her call light. On 04/12/2026 at 10:55 a.m., an observation and concurrent interview was conducted with S4LPN. S4LPN stated Resident #29 used her call light often to call staff for assistance. S4LPN observed and confirmed Resident #29's soft touch call light was on the nightstand and out of the resident's reach. On 04/14/2026 at 2:57 p.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. S2DON confirmed if a resident can use their call light, then their call lights should be kept in reach.

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure: 1.) Medications were administered safely and timely by leaving the medications at the bedside for 2 (#27 and #41) of 31 residents observed during the initial pool; and2.) A Physician's Order was obtained before administering medications for 1 (#27) of 34 residents reviewed in the final sample.Findings:Review of the facility's policy titled Medication Administration with an effective date of 10/04/2024, revealed the following, in part:Policy:Nursing personnel shall ensure the safe and effective administration of medications.Procedure:1. Medication Administration: Prior to administration, the Nursing staff member administering the medication shall ensure that the following steps are accomplished.a. Verify the medication selected matches the order and label.g. Administer the medication as ordered.8. Medication Preparation and Securitya. Immediate administration means the person preparing the medications take it directly to a resident for administration. c. Medications shall not be left unattended . 1.Resident #27 Review of Resident #27's Clinical Record revealed she was admitted to the facility on [DATE].Review of Resident #27's admission MDS with an ARD of 03/15/2026, revealed she had a BIMS of 15, which indicated she was cognitively intact.Review of Resident #27's current Physician Orders revealed the following, in part:Start date-04/13/2026- Melatonin Oral Tablet 5 MG (Melatonin) - Give 5 mg by mouth every 24 hours as needed for insomnia. On 04/12/2026 at 9:15 a.m., an observation was made of a bottle of Melatonin 5 mg on Resident #27's bedside table. On 04/12/2026 at 9:27 a.m., an observation and interview was conducted with S4LPN. of Melatonin 5 mg bottle on resident's bedside. S4LPN confirmed Melatonin bottle should have been returned to the medication cart and not left on Resident #27's bedside table. On 04/13/2026 at 3:45 p.m., an interview was conducted with S5LPN. She reviewed Resident #27's current MAR and stated resident did not have an order for Melatonin. S5LPN confirmed staff should not give residents medications without an order. On 04/15/2026 at 11:27 a.m., an interview was conducted with S4LPN. S4LPN confirmed she provided care for Resident #27 on the evening shift of 04/11/2026. She stated she administered Melatonin 5mg to Resident #27 at 8:00 p.m. medication pass and left the medication in the resident's room. She stated she was unaware Resident #27 did not have an order for Melatonin. S4LPN confirmed medications should not be administered without a Physician's Order and should not be left at a resident's bedside. On 04/14/2026 at 2:53 p.m., an interview was conducted with S2DON. S2DON confirmed medications should not be left at resident's bedside. She further confirmed medications should not be administered without a Physician's Order. 2. Resident #41Review of Resident #41's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Multiple Sclerosis, Unspecified Pain, Gout, Retention of Urine, Hyperparathyroidism, Hyperlipidemia, Dizziness and Giddiness, Essential Primary Hypertension, Nausea With Vomiting, Generalized Abdominal Pain, Epileptic Seizures, Fibromyalgia, Major Depressive Disorder, and Allergic Rhinitis.Review of Resident #41's Significant Change MDS with an ARD of 02/04/2026, revealed she had a BIMS of 13, which indicated she was cognitively intact.Review of Resident #41's current Physician Orders revealed the following, in part:Start date- 12/10/2025- Meclizine HCl 25 mg give 1 tablet by mouth every 6 hours as needed for dizziness; Ondansetron HCl 4 mg give 1 tablet by mouth every 6 hours as needed for nausea/vomiting; Simethicone 80 mg give 1 tablet by mouth every 4 hours as needed for complaint of gas; and Topiramate 100 mg give 1 tablet by mouth two times a day. Start date-12/11/2025- Allopurinol 100 mg give 1 tablet by mouth one time a day; Cinacalcet HCl 30 mg give 1 tablet by mouth one time a day; Fenofibrate 145 mg give 1 tablet by mouth one time a day; Metoprolol Tartrate 25 mg give 1 tablet by mouth one time a day; Zoloft 100 mg give 1 tablet by mouth one time a day; and Cetirizine HCl 10 mg give 1 tablet by mouth one time a day.Start date- 12/12/2025- Phenazopyridine HCl give 1 tablet by mouth every 24 hours as needed for pain.Start date- 03/18/2026- Tramadol HCl 50 mg give 1 tablet by mouth every 6 hours as needed for pain.Start date- 03/25/2026- Vitamin C give 1000 mg by mouth one time a day.Start date- 04/11/2026- Pyridium give 95 mg by mouth one time a day for bladder spasms. On 04/13/2026 at 8:55 a.m., an observation and interview was conducted with Resident #41. An observation was made of one plastic medication cup containing 2 tablets and a second plastic medication cup containing 8 pills were observed on the bedside table with a cup of water. Resident #41 verified the medications in the two plastic cups were her morning medications. She stated she had already taken a couple of the pills and S5LPN left the remaining pills for her to finish taking. On 04/13/2026 at 9:01 a.m., an interview was conducted with S5LPN. She verified there were two plastic medication cups containing 8 pills and 2 tablets on Resident #41's bedside table. She confirmed she did not observe Resident #41 consume all of her morning medications and should have.On 04/14/2026 at 2:53 p.m., an interview was conducted with S2DON. S2DON stated medications should not be left at any resident's bedside. S2DON confirmed the nurse should have observed Resident #41 consume all of her medications prior to exiting room.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#19) of 4 residents reviewed for ADL's. The facility failed to trim and clean Resident #19's fingernails. Findings: Review of Resident #19's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Spastic Hemiplegia affecting Left Non-dominant Side and Cerebral Infarction. Review of Resident #19's current Physician Orders revealed the following:Assess/Trim finger nails and toe nails monthly every day shift on Sunday. Order date: 01/01/2026. Review of Resident #19's current Care Plan revealed the following:Problem: Resident requires staff assistance for ADL care related to Cerebrovascular Accident (CVA) with hemiplegia. Interventions: Assist the resident with hygiene and grooming tasks as needed. On 04/12/2026 at 9:25 a.m., an observation was made of Resident #19 with fingernails noted to be long and dirty. Fingernails observed to extend approximately 1 centimeter past the nailbeds of all 10 fingers. Fingernails noted to have a brown colored substance under each nail. On 04/13/2026 at 1:30 p.m., an observation was made of Resident #19 with fingernails noted to be long and dirty. Fingernails observed to extend approximately 1 centimeter past the nailbeds of all 10 fingers. Fingernails noted to have a brown colored substance under each nail. An interview was conducted with Resident #19 at this time. He stated he would like for his fingernails to be cleaned and trimmed. On 04/13/2026 at 1:35 p.m., an observation was made with S7CNA of Resident #19's fingernails. S7CNA observed Resident #19's fingernails to be long and dirty. She stated CNAs were responsible for cleaning non-diabetic resident's fingernails and this task should be performed with their baths. She stated Resident #19 had received his bath that morning. S7CNA confirmed the resident's fingernails needed to be cleaned and trimmed and should have been completed with his bath. On 04/14/2026 at 2:53 p.m., an interview was conducted with S2DON. S2DON confirmed she expected staff to keep resident's fingernails clean and trimmed.

Based on observations, interviews, and record review, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a nutritional supplement for 1 (#42) of 3 residents reviewed for nutritional status. Findings: Review of Resident #42's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Kidney Disease, Stage 4 Severe, Dependence On Renal Dialysis, and Chronic Systolic Congestive Heart Failure. Review of Resident #42's admission MDS with an ARD of 01/27/2026, revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #42 was on dialysis and received a therapeutic diet. Review of Resident #42's current Physician Orders revealed the following, in part:Start date 04/03/2026 Nepro three times a day. On 04/12/2026 10:13 a.m., an interview was conducted with Resident #42. She stated she was on dialysis and supposed to receive a protein shake with all meals, but did not always get it. She stated her kidney doctor wanted to her to drink the protein shakes three times a day to increase her protein levels. On 04/14/2026 at 12:13 p.m., an observation and concurrent interview was conducted with S7CNA. S7CNA delivered a lunch meal tray to Resident #42's room. An observation of Resident #42's meal ticket was made with S7CNA who confirmed the following: No Added Salt, Renal, Regular Diet, and Nepro supplement lunch. There was no Nepro supplement observed on the meal tray. S7CNA exited Resident #42's room and continued passing meal trays.On 04/14/2026 at 12:20 p.m., an observation and concurrent interview was conducted with S7CNA. She stated when she passed resident meal trays, if a supplement was missing, she went to the kitchen and requested it. She stated she did not observe anything missing from Resident #42's lunch tray. S7CNA observed Resident #42's meal ticket and confirmed a Nepro supplement was not on the meal tray and should have been.On 04/14/2026 at 12:33 p.m., an interview was conducted with S6LPN. She stated Resident #42 was on dialysis, had some weight loss and was ordered Nepro shakes three times a day with meals. She stated the kitchen staff were responsible for ensuring supplements were on the meal trays. She stated the CNAs knew by the meal ticket, Resident #42 should have a Nepro shake with meals. She stated if Resident #42's Nepro shake was not on the meal tray, the CNAs should go to the kitchen and get it or notify her and she would go get it. S6LPN confirmed the CNA who passed Resident #42's lunch tray should have realized the Nepro shake was not there and should have went to the kitchen and gotten one. On 04/14/2026 at 12:51 p.m., an interview was conducted with S9DM. She stated after a supplement was ordered, she updated the resident's meal tickets. She stated the kitchen staff should ensure the supplements were on the meal trays. She stated if the supplement was not placed on the tray, the CNA or nurse on the hall should get the supplement from the kitchen and provide it to the resident. She stated Resident #42 was ordered a Nepro shake with every meal. She stated a Nepro shake should have been provided to Resident #42 for each meal.On 04/14/2026 at 3:00 p.m., an interview was conducted S2DON. She stated the kitchen staff were responsible for ensuring supplements were on the resident's meal trays. She stated if the supplement was not placed on the meal tray, the CNA or nurse on the hall should go get the supplement from the kitchen and provide it to the resident. S2DON verified Resident #42 was ordered Nepro shakes with all meals and should have had one on her lunch tray.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced appropriate infection control practices and proper glove use for 1 (#66) of 1 resident observed for peri-care.Findings: Review of Resident #66's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction. On 04/14/2026 at 10:30 a.m., an observation was made of incontinent care performed by S8CNA. S8CNA donned clean gloves and pulled back Resident #66's bed linens. S8CNA unfastened Resident #66's brief and noted the resident had a bowel movement. She began to clean stool and urine from the resident's perineal area with a wash cloth and perineal cleansing spray. S8CNA did not remove her soiled gloves or perform hand hygiene and then proceeded to turn Resident #66, place a clean brief and clean incontinence pad beneath her, and straighten her gown. On 04/14/2026 at 10:45 a.m., an interview was conducted with S8CNA. She confirmed she should have changed gloves and performed hand hygiene after performing perineal care and prior to applying a clean brief and incontinence pad and did not. On 04/14/2026 at 2:53 p.m., an interview was conducted with S2DON. S2DON confirmed she would expect staff to remove soiled gloves and put on clean gloves before going from dirty to clean when providing peri care.

Based on observations, interviews, and record review, the facility failed to ensure a resident received adequate supervision to prevent elopement for 1 (#3) of 3 residents sampled. The facility failed to ensure S4LPN conducted census checks every two hours as ordered for Resident #3.Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Stroke, Vascular Dementia with Behavioral Disturbance, Cognitive Communication Deficit, and Wernickes's Encephalopathy. Review of Resident #3's annual MDS with an ARD of 01/07/2026, revealed Resident #3 had a BIMS of 8, which indicated he was moderately cognitively impaired. Further review revealed Resident #3 required a wander/elopement alarm. Review of Resident #3's Elopement Risk Evaluation, dated 01/07/2026, revealed Resident #3 was an elopement risk because he had expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Further review revealed Resident #3 would continue to use a wanderguard as ordered. Review of Resident #3's physician orders revealed the following:Order/start date: 06/23/2025: Wanderguard census checks - every 2 hours. Review of Resident #3's current care plan revealed the following, in part:Problem: The resident was an elopement risk/wanderer. The resident made statements about leaving facility. The resident wears a wanderguard.Goal: The resident's safety will be maintained through the review date: 03/01/2026.Interventions: The resident wears a wanderguard as ordered.Problem: The resident had a diagnosis of dementia and had impaired cognitive status.Goal: The resident will maintain current level of cognitive function through review date: 03/01/2026.Interventions: Cue, reorient and supervise as needed. The resident required assistance with decision making. Review of Resident #3's MARs dated December 2025 through February 2026 revealed the following: Wanderguard census checks - every two hours. Further review revealed the census checks were not completed as ordered on 02/11/2026 for the 7:00 a.m. through 7:00 p.m. shift revealed the census checks were not completed as ordered. S4LPN conducted one census check on 02/11/2026 at 10:48 a.m. On 02/11/2026 at 2:07 p.m., observations and an interview were conducted with Resident #3. Resident #3 was observed lying in his bed fully dressed, wearing shoes, and a wanderguard was not in place. Resident #3 stated he had removed his wanderguard approximately one month ago. and he verbalized a need to get home to [NAME] the grass and grate his driveway. Further observation revealed Resident #3's wanderguard was in the top drawer of his bedside table. On 02/11/2026 at 2:16 p.m., an interview was conducted with S3NP. S3NP confirmed Resident #3 had an order for a wanderguard due to being an elopement risk and stated Resident #3 was often confused. S3NP observed and interviewed Resident #3, and confirmed he did not have a wanderguard in place, and should have. S3NP further confirmed Resident #3's wanderguard was located in his bedside table. On 02/11/2026 at 2:47 p.m., an interview was conducted with S4LPN. S4LPN confirmed she was assigned to care for Resident #3 and he had an order for a wanderguard. S4LPN stated she was unaware Resident #3's wanderguard was not in place. S4LPN stated she performed a census check for Resident #3 once during her shift on 02/11/2026. After reviewing Resident #3's MAR, S4LPN confirmed Resident #3 had an order for census checks every two hours. S4LPN stated she checked Resident #3's wanderguard at 10:48 a.m. on 02/11/2026 and it was in place. S4LPN confirmed she did not conduct census checks every two hours on 02/11/2026 for Resident #3 as ordered and should have. On 02/11/2026 at 3:00 p.m., an interview was conducted with S2DON. S2DON stated she observed and interviewed Resident #3. S2DON confirmed Resident #3 did not have a wanderguard in place, and should have. S2DON further confirmed S4LPN should have conducted census checks for Resident #3 every two hours as ordered and did not.

Based on observations, interviews and record reviews, the facility failed to ensure there was sufficient numbers of direct care staff to provide timely assistance with baths/showers for 4 of 4 (#5, #8, #9, and #10) residents reviewed for baths/showers. This deficient practice had the potential to affect any of the 81 residents residing in the facility. Findings: Review of the facility's Bath, Shower Policy and Procedure, effective 09/04/2014, revealed, in part, the following:Policy: Showers are to be given as scheduled and/or as needed. Procedure: NOTE: Never leave the resident alone in the shower room. Review of the facility's Resident Council Meeting Minutes, dated 09/09/2025, revealed, in part, Resident #5, #8, #9, and #10 participated in the meeting. Further review revealed the residents in attendance agreed the new bath/shower process was not working and no one received their baths/showers at their scheduled times. An observation was conducted on 09/09/2025 at 8:25 a.m. of Resident #8 and 2 other residents, seated in wheelchairs in the hallway outside of the bath/shower room waiting to receive their bath/shower. An observation was conducted on 09/09/2025 at 9:05 a.m. of Resident #8 and the same 2 residents, seated in wheelchairs in the hallway outside of the bath/shower room waiting to receive their bath/shower. An observation was conducted on 09/09/2025 at 9:35 a.m. of Resident #8, #10, and one other resident seated in wheelchairs in the hallway outside of the bath/shower room waiting to receive their bath/shower. An observation was conducted on 09/09/2025 at 9:45 a.m. Resident #8 and #10, and one other resident seated in wheelchairs in the hallway outside of the bath/shower room waiting to receive their bath/shower.Resident #5Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Unspecified Congestive Heart Failure (CHF).Review of Resident #5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/2025, revealed, in part, a BIMS of 14, which indicated she was cognitively intact. Review of Resident #5's Plan of Care, as of 08/06/2025, revealed, in part, the following:Resident required staff assistance for ADL care. Resident required limited to moderate assistance with ADL's. Resident needs met per herself and staff.Interventions:Assist resident with bathing.An interview was conducted on 09/10/2025 at 8:35 a.m. with Resident #5. Resident #5 stated she had to clean herself up in her sink in the mornings when her CNA was not available to give her a bath/shower. She stated the facility had a bath/shower situation and she was not receiving regular baths or was having to wait hours for a bath/shower. She stated there were not enough CNAs to get everything done. Resident #8Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Chronic Obstructive Pulmonary Disorder (COPD), Severe Morbid Obesity, Generalized Muscle Weakness, Abnormalities of Gait and Mobility, and Hidradenitis Suppurativa (HS). Review of Resident #8's quarterly MDS with an ARD of 07/30/2025, revealed, in part, the resident was assessed by the facility to have a BIMS of 15, which indicated he was cognitively intact. Review of Resident #8's Plan of Care, as of 09/10/2025, revealed, in part, the following:Resident diagnosed with HS.Resident required staff assistance for ADL care.Resident required limited to extensive assistance with ADL's. Resident needs met per himself and staff.Interventions:Assist resident with bathing.An observation and interview was conducted on 09/09/2025 at 9:10 a.m. with Resident #8 in line outside of the bath/shower room. He stated he had a skin condition, HS, which required him to take a bath/shower first thing every morning to prevent further outbreak and control the odor it caused. He confirmed he got in line for his bath/shower this morning a little after 8:00 a.m. and was still waiting. He stated he was the Resident Council President and called a meeting today due to resident complaints of long wait times for baths/showers since the facility no longer utilized Shower Aides. He stated almost two weeks ago the facility removed 2 shower aides from the daily assignments Monday through Friday. He stated since that time, he had waited in excess of two to three hours each morning to receive his daily bath. He stated there was almost never less than three residents waiting in line in the hallway for a bath/shower. He confirmed he required staff assistance to take his bath/shower and could not perform the task independently. He confirmed he had missed some activities within the facility because he was waiting in line to receive his bath. He confirmed the facility's Administration was aware of the delays and had not done anything to improve it. Resident #8 stated he blamed the facility for not having enough staff.An interview was conducted on 09/09/2025 at 10:30 a.m. with S7NP. S7NP confirmed due to Resident #8's diagnosis of HS, he had numerous open lesions on his body which caused a noticeable odor. S7NP confirmed Resident #8 required a bath first thing every morning 7 days a week to remove the bacteria on his skin in order to prevent further infection and additional lesions, as well as, to control the odor his condition caused. Resident #9Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Severe Morbid Obesity and CHF.Review of Resident #9's annual MDS, with an ARD of 08/13/2025, revealed, in part, the resident was assessed by the facility to have a BIMS of 14, which indicated she was cognitively intact. Review of Resident #9's Plan of Care, as of 09/10/2025, revealed, in part, the following:Personalized Care Goal: Staff will accommodate/support valued activities in care routine. Interventions: Bathing preference - Shower.Resident required extensive staff assistance with ADL's. An interview was conducted on 09/10/2025 at 10:50 a.m. with Resident #9. She stated she was tired of waiting hours to get her bath/shower. She stated she waited in her wheelchair for over three and a half hours earlier this week to receive her bath, which was unacceptable. She confirmed the three hour wait was typical since the facility no longer utilized Shower Aides. She stated there weren't enough CNAs to get everything done. Resident #9 confirmed she informed staff of her needs not being met and voiced her concerns during the aforementioned Resident Council Meeting. Resident #10Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, History of Falling, COPD. Review of Resident #10's quarterly MDS, with an ARD of 06/18/2025, revealed, in part, the resident was assessed by the facility to have a BIMS of 12, which indicated he was moderately cognitively impaired. Review of Resident #10's Plan of Care, as of 09/10/2025, revealed, in part, the following:Resident required supervision to limited assistance with ADL's. Interventions: Assist resident with bathing.An interview was conducted on 09/10/2025 at 8:45 a.m. with Resident #10. He stated the facility's biggest issue right now was extended wait times for showers/baths due to the facility eliminating the 2 Shower Aides. Resident #10 confirmed no matter what staff might say, prior to his bath yesterday, he had not received a shower from staff in 3 weeks because the facility was shorthanded. An interview was conducted on 09/09/2025 at 9:40 a.m. with S8US. S8US confirmed from the unit secretary's desk, she had a clear view of the hallway outside one of the bath/shower rooms. S8US confirmed the facility no longer utilized shower aides. S8US confirmed prior to the change, there were 2 Shower Ades performing baths/showers from 6:00 a.m. until at least 2:00 p.m. in order to complete them. S8US confirmed since the Shower Aides were removed, there were typically 2 to 4 residents waiting in line in the hallway to receive their bath/shower during the mornings. An interview was conducted on 09/09/2025 at 9:45 a.m. with S9CNA. S9CNA stated until recently she served as one of the facility's 2 Shower Aides. S9CNA stated when she was a Shower Aide, she worked Monday through Friday from 6:00 a.m. until at least 2:00 p.m. in order to get all of her baths/showers completed. S9CNA confirmed about 2 weeks ago the facility told them there would be no more Shower Aides to give baths/showers during the day. S9CNA stated she was told she would start working as a floor CNA and the floor CNAs would now be responsible for performing their own baths/showers throughout their shift in addition to all of their previously assigned tasks. S9CNA confirmed her current resident assignment included her being solely responsible for a total of 11 residents; 4 residents were 2 person assist, 1 resident required total feeding assistance, 10 residents were set up assistance with all meals, and all 11 residents were incontinent and required turning, repositioning and incontinence care every 2 hours at a minimum. S9CNA confirmed while the CNAs were tied up performing all of the aforementioned regular floor CNA duties, they weren't able to perform baths/showers which meant the residents had to wait until they were available. S9CNA confirmed a 2 to 3 hour wait time for a bath/shower was typical and could be longer depending on the time of day. An interview was conducted on 09/08/2025 at 1:30 p.m. with S10CNA. S10CNA stated at times she could be assigned to independently cover 2 and a half halls which included a total of 28 residents. S10CNA confirmed numerous residents were total care 2 person assist and required incontinence care and turning/repositioning every 2 hours which took her away from performing her scheduled baths/showers. S10CNA stated her current workload made it impossible for her to perform baths/showers when her residents wanted them. An interview was conducted on 09/09/2025 at 2:30 p.m. with S12CNA. S12CNA stated the facility recently made a process change in the assignments and duties for CNA staff. S12CNA stated when this occurred, the facility removed the 2 Shower Aides and the floor CNA's were expected to perform all assigned baths/showers and bed baths in addition to all of their previous duties and tasks. S12CNA stated her assignment consisted of 4 to 5 residents who required 2 person assist for changing, turning/repositioning every 2 hours, which took her away from completing her baths/showers and made it impossible to complete them when residents preferred. S12CNA confirmed she felt the new system was not working well and caused delays in residents receiving timely baths/showers. An interview was conducted on 09/10/2025 at 2:30 p.m. with S2DON. S2DON confirmed the facility made a system change on 09/05/2025 which removed the 2 Shower Aides and placed them as floor CNAs. S2DON confirmed the facility was still working out the kinks since removing the Shower Aides which caused extended wait times for residents to have their needs met. S2DON confirmed the facility should have enough staff to ensure residents received timely baths/showers but the facility had not yet figured out how to make it work with the new system. An interview was conducted on 09/10/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed the facility made a change on 09/05/2025 which removed the 2 Shower Aides and placed them as floor CNAs. S1ADM confirmed the facility was still working out the kinks since removing the Shower Aides which caused extended wait times for residents to have their needs met. S1ADM confirmed residents should not have to suffer or have any of their needs unmet while this occurred. S1ADM confirmed the facility should have enough staff to ensure residents received timely bath/showers and were not lining the hallways like cattle for extended periods in order to receive a bath/shower.

Based on observations, interviews, and record review, the facility failed to ensure residents with Pressure Ulcers received care consistent with professional standards of practice by failing to ensure:1. The nurse documented the date and their initials on the dressings of each treatment performed for 2 (#3 and #4) of 4 (#3, #4, #5, and #6) residents reviewed with Pressure Ulcers; and 2. The nurse applied dressings large enough to fully cover and protect the wounds for 1 (#4) of 4 (#3, #4, #5, and #6) residents reviewed with Pressure Ulcers. Findings: Review of the facility's Wound Care Policy and Procedure, effective 11/26/2014, revealed, in part, the following:Treatment Orders: After observation/evaluation of the affected skin area, implement standing orders. Applying Treatment: 1. Date and Initial each Dressing Nursing Interventions: 1. Local Care a. Cleansing and dressing as ordered and appropriate 2. Keep resident clean and dry Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer, Unspecified Stage, Bacterial Infection, Spastic Quadriplegic, and Cerebral Palsy. Review of Resident #3's Current Physician Orders revealed the following:Start date- 09/02/2025. Pressure ulcer right anterior hip clean with normal saline/wound cleanser, pat dry apply Dakin soaked dressing, apply barrier of choice, and cover with clean dry dressing daily. Start date- 09/08/2025. Pressure Ulcer to left hip to sacral clean with normal saline/wound cleanser, pat dry apply medical/honey, apply barrier of choice, and cover with clean dry dressing daily. An observation was conducted on 09/08/2025 at 08:55 a.m. of Resident #3's sacrum dressing not fully covering pressure wound area. An observation was conducted on 09/08/2025 at 10:30 a.m. of Resident #3's dressings to the bilateral heels, sacrum, and right ischium. The dressings were observed without the date the treatment was performed or the initials of the person who performed the treatment. An observation and interview was performed on 09/08/2025 at 11:20 a.m. with S6LPN. S6LPN confirmed she was the facility's Wound Treatment Nurse and performed wound treatments Monday through Friday. S6LPN confirmed she did not perform Resident #3's wound treatment on 08/06/2025 or 08/07/2025 and was not aware who served as the treatment nurse on those dates. S6LPN confirmed Resident #3's dressings did not contain the date the treatment was performed or the initials of the person who performed the treatment, and should have. S6LPN confirmed this information was important to have on the dressing to indicate it was performed on time as ordered and to be used as a point of reference to determine the amount of drainage present from a specific timeframe. An interview was conducted with S11CNA on 09/08/2025 at 11:30 a.m. S11CNA confirmed Resident #3's dressing did not have date and initials on dressing prior to being removed. Resident #4 Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis which included Pressure Ulcer of Sacral Region, Stage 4. Review of Resident #4's Current Physician Orders revealed the following:Start date- 09/02/2025. Pressure ulcer to sacral wound area- clean with normal saline/wound cleanser pat dry apply mesalt and calcium alginate apply barrier of choice and cover with clean dry dressing daily. An observation was conducted on 09/08/2025 at 10:40 a.m. of Resident #4's dressing to the sacrum. The dressing did not extend past the edges of the wound, leaving a 3 inch x 3 inch portion of her sacral wound open to air with no protective covering. Observation also revealed the dressing did not contain the date the treatment was performed or the initials of the person who performed it. An observation and interview was performed on 09/08/2025 at 11:20 a.m. with S6LPN. S6LPN confirmed Resident #4's sacral dressing did not extend beyond the edges of her wound which left an area 3 inches x 3 inches exposed to contaminants and this should not happen. S6LPN confirmed all wounds with orders to cover with a dressing should have a dressing in place which extended beyond the edges of the wound to fully cover it and prevent anything from coming in contact with the wound. S6LPN further confirmed Resident #4's dressing did not contain the date the treatment was performed or the initials of the person who performed the treatment and should have. An interview was conducted on 09/09/2025 at 10:30 a.m. with S7NP. S7NP confirmed Residents #3 and #4 had orders to keep pressure ulcer wound covered. S7NP confirmed importance of wound dressings to be dated and timed to determine the amount of drainage present at a specific timeframe. S7NP confirmed if the treatment order called for the wound to be covered with a dressing, she expected the dressing to be large enough to fully cover wound, leaving no openings to air or exposure to contaminants. S7NP confirmed leaving a wound open to air that should be covered greatly increased the risk of the wound becoming infected and should not occur. An interview was conducted on 09/10/2025 at 2:47 p.m. with S2DON. S2DON confirmed both Residents #3 and #4 received wound care for pressure ulcers. S2DON further confirmed dressings should completely cover wounds as per orders, include date of dressing change, and the initials of the person performing the treatment. An interview was conducted on 09/10/2025 at 2:47 p.m. with S1ADM. S1ADM confirmed she expected staff to follow orders and policy in regards to wound care treatments.

Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#4) of 2 (#4 and #R1) residents reviewed for enteral feedings. The facility failed to ensure the enteral feeding bag was appropriately labeled with a date, time, and nurse initials. Based on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#4) of 2 (#4 and #R1) residents reviewed for enteral feedings. The facility failed to ensure the enteral feeding bag was appropriately labeled with a date, time, and nurse initials. Findings: Review of the facility's policy titled, Enteral Nutritional Therapy, dated 01/14/2016 revealed the following: Enteral Nutritional Therapy is to be given as ordered by the physician.11. Change formula container per facility procedure.Review of the clinical record for Resident #4 revealed she was re-admitted to the facility on [DATE] (original admission date to facility 12/18/2020) with diagnoses which included Gastrostomy Status. Review of the current Physician Orders for Resident #4 revealed, in part, the following: Start date: 05/30/2025 - Enteral Nutrition via feeding pump- Diabetisource via Peg (percutaneous enteral gastrostomy) at 60 ml (milliliter) per hour continuous secondary to dysphagia. Start date: 09/12/2024 - Closed system container- Change feeding administration set with each new bottle; label the formula container, syringe, and administration set with the resident's name, date, time, and nurse's initials. An observation was made on 09/08/2025 at 10:15 a.m. of Resident #4. Resident #4's enteral feeding solution was infusing at 60 ml/hour with no labeling of date, time or nurse initials noted on the formula container. An interview was conducted on 09/08/2025 at 10:40 a.m. with S5LPN. S5LPN confirmed Resident #4's hanging bag of enteral feeding should have been labeled with a date, time, and nurse's initials and was not. An interview was conducted on 09/10/2025 at 2:20 p.m. with S2DON. S2DON confirmed an enteral feeding bag should be labeled with the date, time, and nurse's initials at the start of infusion. An interview was conducted on 09/10/2025 at 2:25 p.m. with S1ADM. S1ADM confirmed expectation was for staff to follow physician orders and facility policy for administration of enteral feedings.

Based on observations, interviews, and record reviews, the facility failed to have a measurable evaluation system in place to ensure nursing staff were trained and competent to perform wound treatments as ordered prior to being allowed to independently perform them. This deficient practice was evidenced by failure to ensure: 1. The nurse documented the date and their initials on the dressing of each treatment performed for 1 (#3 and #4) of 4 (#3, #4, #5, and #6) residents present in the facility who were reviewed for wounds; and 2. The nurse applied a dressing large enough to fully cover and protect the wound for 1 (#4) of 4 (#3, #4, #5, and #6) residents present in the facility who were reviewed for wounds. This deficient practice had the potential to affect any of the facility's 31 wounds with active treatment orders. Findings: Review of the facility's Wound Care Policy and Procedure, effective 11/26/2014, revealed, in part, the following:Treatment Orders: After observation/evaluation of the affected skin area, implement standing orders. Applying Treatment: 1. Date and Initial each Dressing Nursing Interventions: 1. Local Care a. Cleansing and dressing as ordered and appropriate 2. Keep resident clean and dry Review of the facility's Staff Assignments, dated 09/06/2025 through 09/07/2025, revealed, in part, the following: 09/06/2025 (Saturday): Wound Treatment Nurse - S4MDS; and09/07/2025 (Sunday): Wound Treatment Nurse - S4MDS.Review of S4MDS's Personnel File revealed she was a Licensed Practical Nurse who was hired to work at the facility on 09/27/2018 and currently served as the facility's Minimum Data Set (MDS) and Care Plan Nurse. Review of S4MDS's Annual Training and Competency Evaluation, dated 08/29/2025, revealed, in part, S3SD initialed indicating she observed S4MDS perform the following tasks with competency demonstrated: Skin Integrity Program - Treatments and Documentation. 1.An observation was conducted on 09/08/2025 at 10:30 a.m. of Resident #3's dressings to the bilateral heels, sacrum and right ischium. The dressings were observed without the date treatment was performed and/or the initials of the person who performed the treatment. An observation and interview was performed on 09/08/2025 at 11:20 a.m. with S6LPN. S6LPN confirmed she was the facility's Wound Treatment Nurse and performed wound treatments Monday through Friday. S6LPN confirmed the facility utilized various nursing staff from all areas of the facility to perform treatments on Saturdays and Sundays and the person performing them varied from week to week. S6LPN confirmed she did not perform Resident #3's wound treatment on 09/06/2025 or 09/07/2025 and was not aware who served as the treatment nurse on those dates. S6LPN confirmed she did not conduct any training or evaluation of competency in regards to wound treatments for floor nurses or the nurses who filled in as Weekend Treatment Nurse. S6LPN confirmed Resident #3's dressings did not contain the date the treatment was performed and/or the initials of the person who performed the treatment and should have. S6LPN confirmed this information was important to have on the dressing to indicate it was performed on time as ordered and to be used as a point of reference to determine the amount of drainage present from a specific timeframe. 2. An observation was conducted on 09/08/2025 at 10:40 a.m. of Resident #4's dressing to the sacrum. The dressing did not extend past the edges of the wound, leaving a 3inch x 3 inch portion of her sacral wound open to air with no protective covering. The dressing did not contain the date the treatment was performed and/or the initials of the person who performed it. An observation and interview was performed on 09/08/2025 at 11:20 a.m. with S6LPN. S6LPN confirmed she did not perform Resident #4's wound treatment on 09/06/2025 or 09/07/2025 and was not aware who did. S6LPN confirmed Resident #4's sacral dressing did not extend beyond the edges of her wound which left an area 3 inches x 3 inches exposed to contaminants and this should not happen. S6LPN confirmed all wounds with orders to cover with a dressing should have a dressing in place which extended beyond the edges of the wound to fully cover it and prevent anything from coming in contact with the wound. S6LPN confirmed Resident #4's dressing did not contain the date the treatment was performed and/or the initials of the person who performed the treatment and should have. An interview was conducted on 09/09/2025 at 8:50 a.m. with S4MDS. S4MDS confirmed she was the facility's MDS and Care Plan Nurse but due to the facility no longer utilizing agency staff, the administrative nurses were assigned to be on-call to cover shifts at least 5 days a month and could be called in to work direct care when and where they were needed. S4MDS confirmed when she arrived to start her shift on 09/06/2025, she thought she would be working as a floor nurse on 09/06/2025 and 09/07/2025 but was told she would be performing wound treatments. S4MDS confirmed she had never been a Wound Treatment Nurse and prior to 09/06/2025, she had not performed wound treatments in over a year. S4MDS confirmed on 09/06/2025, after she found out she would be performing wound treatments, she printed the treatment orders for all of the residents in the facility then found the wound cart to figure out what to do per the printed treatment orders. S4MDS confirmed she went resident to resident and did the best she could but was not certain if she applied all of the treatments per product specifications. S4MDS confirmed she performed all wound treatments on 09/06/2025 and 09/07/2025 and was not aware she should have dated/initialed the dressings when she applied them to the wounds. S4MDS confirmed she used the dressings she could find and did her best to ensure the wounds were fully covered. S4MDS reviewed her aforementioned Annual Training and Competency Evaluation and confirmed she was not provided with training regarding the performance of wound treatments. S4MDS confirmed S3SD had not observed her performing wound treatments to ensure she was competent in the task. S4MDS confirmed S3SD asked her if she had performed wound treatments in the past, had her initial next to each item then S3SD went behind her and initialed as well. An interview was conducted on 09/10/2025 at 1:10 p.m. with S3SD. S3SD confirmed she was responsible for the facility's Staff Development which included training and evaluation of skills competency for nursing staff. S3SD confirmed she considered the performance of wound treatments to be a specialized skill which would require specialized training(s). S3SD confirmed she had never been a wound treatment nurse, had not received wound treatment training and did not consider herself competent in the performance of wound care treatments so she would not be able to train and/or perform the evaluation of competency for this specialized skillset. S3SD confirmed each nurse completed a Training and Competency Evaluation form upon hire then annually thereafter. S3SD confirmed she was responsible for completing this form with the employee. S3SD confirmed when a nurse was hired, she asked them if they had previously performed the skills on the list and if they had, she instructed them to initial next to the line item. S3SD confirmed she did not provide training on all of the line items listed on the form, she just verified the nurse had received training and/or performed the task at some point since they became a licensed nurse. S3SD confirmed if they told her they had not, either she or a floor nurse would perform the training. S3SD confirmed after the employee completed the form, she signed her initials under the competency column. S3SD confirmed her initials on the form did not indicate she evaluated the nurse's skill(s) only that she asked the nurse if they had performed the task before. S3SD confirmed she took the nurse's word for it when they said they were competent to perform the skills required for their position. S3SD confirmed the facility did not currently have a system in place to ensure all nurses assigned to perform wound treatments were trained and/or evaluated as being competent in performing the treatments prior to allowing them to do so. S3SD stated if a nurse was responsible for performing wound treatments, they were expected to print the wound orders then follow them. An interview was conducted on 09/09/2025 at 10:30 a.m. with S7NP. S7NP confirmed she had not provided training or performed a skills competency evaluation regarding wound treatments for S4MDS or anyone other than S6LPN. S7NP confirmed training in wound treatments then evaluating to confirm the competency of the floor nurses and/or weekend treatment nurse(s) would be the responsibility of the facility. S7NP confirmed when a wound treatment was performed, the person performing it should document the date and their initials on the wound's dressing. S7NP confirmed this information was important to have on the dressing to indicate it was performed on time, as ordered and to be used as a point of reference to determine the amount of drainage present from a specific timeframe. S7NP confirmed when a wound treatment was performed, if the treatment order called for the wound to be covered with a dressing, she expected the dressing to be large enough to extend beyond the edges of the wound leaving no areas of the wound open to air or exposed to potential contaminants. S7NP confirmed leaving a wound open to air that should be covered greatly increased the risk of the wound becoming infected and should not occur. An interview was conducted on 09/10/2025 at 2:30 p.m. with S2DON. S2DON confirmed the performance of wound treatments was considered a specialized skill and would require specialized training followed by an evaluation to confirm competency in the skill(s). S2DON stated the facility hired licensed nurses and as a licensed nurse the facility expected them to be trained and competent to perform the tasks they were required to perform within the facility. S2DON confirmed S3SD taking a nurse's word for it when asked if they were trained and competent in a skillset would not take the place of actually providing the training and performing an evaluation of competency. S2DON confirmed the presence of S3SD's initials on S4MDS' aforementioned Training and Evaluation of Competency did not indicate she provided the training and/or performed an evaluation of S4MDS' competency. An interview was conducted on 09/10/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed the performance of wound treatments was considered a specialized skill and would require specialized training followed by an evaluation to confirm competency in the skill(s). S1ADM stated the facility hired licensed nurses and as a licensed nurse the facility expected them to be trained and competent to perform the tasks they were required to perform within the facility. S1ADM confirmed S3SD taking a nurse's word for it when asked if they were trained and competent in a skillset would not take the place of actually providing the training and performing an evaluation of competency. S1ADM confirmed the presence of S3SD's initials on S4MDS' aforementioned Training and Evaluation of Competency did not indicate she provided the training and/or performed an evaluation of S4MDS' competency.

Based on observation, interviews and record reviews, the facility failed to have a system in place to ensure the safe disposition and administration of resident medications for 1 (#2) of 3 (#2, #4, and #5) residents present in the facility who were reviewed for medications. This deficient practice was evidenced by Resident #2, who was not assessed for and did not have a physician's order for self-administration of medications, having an inhaler left at bedside.Findings: Review of the facility's Self Administration of Medication Policy and Procedure, effective 12/05/2014, revealed, in part, the following:Policy: Each resident will be assessed on admission, quarterly, annual, any significant change in condition and as needed for self-administration of medication if applicable. Procedure: 1. A Self-Administration of Medication Assessment will be completed as indicated. 2. Interdisciplinary Team (IDT) will review assessment and determine if resident is safe to administer medication. 3. IDT will determine who will be responsible (resident or nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration. 1. If resident is deemed safe: a. Physician order will be written b. Nursing will monitor weekly and as needed. 2. Care plan will be updated. Equipment: 1. Self-Administration of Medication Assessment2. High Risk Meeting3. Care PlanAn observation was conducted 09/08/2025 at 8:40 a.m. of Resident #2's Albuterol Sulfate Inhaler lying on the bedside table next to her bed with no staff present. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with Chronic Obstructive Pulmonary Disorder (COPD); Cognitive Communication Deficit; Lack of Coordination; Weakness; and a Disorder of Brain.Review of Resident #2's Quarterly Minimum Data Set (MDS) with a modification Assessment Record Date (ARD) of 06/25/2025 revealed she was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. Further review of Section G - Functional Status revealed, in part, the following: Eating: Supervision or touching assistance; Oral Hygiene: Partial/Moderate Assistance; Toileting: Substantial/Maximal Assistance; Shower/Bathe: Substantial/Maximal Assistance; Dressing: Substantial/Maximal Assistance; Footwear: Dependent. Review of Resident #2's active Physician Orders, as of 09/08/2025 at 9:50 a.m., revealed no active orders for Resident #2 to self-administer medications or to have medications left at bedside. Further review revealed, in part, an order written on 06/03/2024 for Albuterol Sulfate Inhaler 108 micrograms (mcg)/actuation (act). Inhale 2 puffs every 6 hours as needed for wheezing related to COPD. Review of Resident #2's Care Plan, as of 09/08/2025 at 9:53 a.m., revealed she was not currently careplanned to self-administer medications or to have medications left at bedside. Review of Resident #2's's MAR, dated 08/01/2025 through 09/08/2025, revealed, in part, no documented evidence of Resident #2's Albuterol Sulfate Inhaler being administered at any time during the aforementioned period. An interview and observation was conducted on 09/08/2025 at 8:42 a.m. with S5LPN. S5LPN confirmed Resident #2's Albuterol Sulfate Inhaler was left unattended on her bedside table in her room. S5LPN confirmed Resident #2 did not have an order for the inhaler to remain at bedside or to self-administer her own medications. S5LPN confirmed an assessment for safe self-administration of medications was required for a resident to have medications left at bedside and Resident #2 had not received this assessment. S5LPN confirmed a physician's order was also required for a resident to keep medications at bedside in order to self-administer and Resident #2 did not have such an order. S5LPN confirmed Resident #2's medications should remain locked in the medication cart at all times when a nurse was not actively administering it to the resident. S5LPN reviewed Resident #2's Medication Administration Record (MAR) and confirmed the last time a nurse documented administering her Albuterol Sulfate Inhaler was in July 2025. S5LPN confirmed the MAR documentation could not be accurate because Resident #2 required frequent use of her inhaler to treat her shortness of breath. An interview was conducted on 09/10/2025 at 2:30 p.m. with S2DON. S2DON confirmed any resident who wished to self-administer their own medications and have them left at bedside would require an assessment to determine if they were safe to do so along with a physician's order indicating they were approved to self-administer medications and if they were allowed to have the medication left at bedside. S2DON confirmed Resident #2 had not been assessed for safe self-administration of medications and did not have a physician's order to self-administer so her Albuterol Sulfate Inhaler should not have been left at bedside. S2DON confirmed Resident #2's medications should remain locked in the medication cart at all times when a nurse was not actively administering it to her. S2DON confirmed even when a resident was allowed to self-administer, the date/time when the resident self-administered the medication should be documented on the resident's MAR by their nurse and it was not for Resident #2. An interview was conducted on 09/10/2025 at 2:30 p.m. with S1ADM. S1ADM confirmed any resident who wished to self-administer their own medications and have them left at bedside would require an assessment to determine if they were safe to do so along with a physician's order indicating they were approved to self-administer medications and if they were allowed to have the medication left at bedside. S1ADM confirmed Resident #2 had not been assessed for safe self-administration of medications and did not have a physician's order to self-administer so her Albuterol Sulfate Inhaler should not have been left at bedside. S1ADM confirmed Resident #2's medications should remain locked in the medication cart at all times when a nurse was not actively administering it to her. S1ADM confirmed even when a resident was allowed to self-administer, the date/time when the resident self-administered the medication should be documented on the resident's MAR by their nurse and it was not for Resident #2.

Based on record reviews and interviews, the facility failed to ensure that each resident's comprehensive and non-comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 5 of 20 (#24, #29, #37, #57, and #60) resident records reviewed in the final sample. The facility failed to submit Resident assessments within 14 calendar days as required. Findings: Resident #24 Review of Resident #24's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2025, revealed a complete by date of 05/07/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #29 Review of Resident #29's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2025, revealed a complete by date of 05/10/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #37 Review of Resident #37's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2025, revealed a complete by date of 05/08/2025. Further review of the MDS revealed the MDS had a status of in progress. Review of Resident #37's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/05/2025, revealed a complete by date of 05/19/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #57 Review of Resident #57's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2025, revealed a complete by date of 05/14/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #60 Review of Resident #60's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2025, revealed a complete by date of 05/04/2025. Further review of the MDS revealed the MDS had a status of in progress. On 05/21/2025 at 12:56 p.m., an interview was conducted with S13MDS. She reviewed Resident #57's Quarterly MDS assessment. She further reviewed Resident #24, #29, #37 and #60's Discharge Assessments. She confirmed status for all aforementioned assessments as being in progress and had not been completed in required timeframe. She stated Quarterly and Discharge MDS assessments should be completed within 14 days and were not. On 05/21/2025 at 2:10 p.m., an interview was conducted with S2RNSUP. She reviewed Resident #57's Quarterly MDS assessment. She further reviewed Resident #24, #29, #37 and #60's Discharge Assessments. S2RNSUP confirmed status for all aforementioned assessments as being in progress and had not been completed in required timeframe. S2RNSUP stated Quarterly and Discharge MDS assessments should be completed within 14 days and were not. 47191

Based on observations, interviews, and record reviews, the facility failed to provide sufficient nursing staff to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure: 1. Staff assisted resident's request for assistance with ADLs timely for 3 (#6, #31, and #60) of 13 residents reviewed on Hall B; and 2. S7LPN was aware Resident #32 was at the facility for a time period of 3-4 hours when she refused to go to dialysis. Findings: Review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1 revealed a one-star staffing rating. Review of the facility's census dated 05/18/2025 revealed there was a total census of eighty-four residents and seven halls. Further review revealed there were thirteen residents residing on Hall B. Review of the facility's Daily Assignment Sheet dated 05/20/2025 revealed the following, in part: 6:00 a.m. to 2:00 p.m.: S17CNA - Hall B Further review revealed no other CNA's assigned to Hall B. 1. Resident #6 Review of Resident #6's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Generalized Muscle Weakness and Morbid Obesity. Review of Resident #6's Significant Change MDS with ARD of 03/06/2025 revealed BIMS of 15, which indicated she was cognitively intact. Further review revealed she required substantial/maximal assistance for toileting and rolling left to right. On 05/20/2025 at 8:00 a.m., an observation was made of the Hall B. There were thirteen residents on Hall B and 1 CNA, S17CNA, was observed on the hall. On 05/20/2025 at 8:10 a.m., an interview was conducted with Resident #6. She stated the CNA's had too many residents on Hall B to take care of. She stated there was 1 CNA who worked Hall B. She stated she had been told by a CNA before to urinate in her brief two times before she called to be changed. She stated sometimes it was 3 hours between CNA rounds. On 05/20/2025 at 8:55 a.m., an observation was made of S17CNA walking into Resident #6's room then exiting. On 05/20/2025 at 8:57 a.m., an interview was conducted with Resident #6. She stated she had just soiled herself and she let S17CNA know when she was just in her room. She stated S17CNA brought some briefs in her room, then left. On 05/20/2025 at 9:46 a.m., an observation was made of S17CNA entering Resident #6's room with a brief, a pad, and gloves. At 9:54 a.m., S17CNA exited Resident #6's room. Resident #31 Review of Resident #31's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Review of Resident #31's Quarterly MDS with an ARD of 03/26/2025 revealed she was unable to complete the BIMS interview. Further review revealed she required substantial/maximal assistance for toileting hygiene and rolling right to left. Review of Resident #31's current Physician Orders revealed the following, in part: Turn every 2 hours as appropriate, monitor every shift related to decreased mobility, incontinence, high risk breakdown and skin integrity. Review of Resident #31's current Care Plan revealed the following, in part: Resident is high risk for skin breakdown related to incontinence and fragile skin. The resident is on an every 2 hour turning and repositioning program. On 05/20/2025 at 8:02 a.m., an observation was made of S17CNA exiting Resident #31's room, and entering the room next door. On 05/20/2025 from 8:00 a.m. to 11:35 a.m., an observation was made of Hall B. S17CNA nor were any other staff observed entering Resident #31's room after 8:02 a.m. Resident #60 Review of Resident #60's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Mycobacterial Infections. Review of Resident #60's Admission MDS with an ARD of 04/18/2025 revealed a BIMS of 15, which indicated he was cognitively intact. Further review revealed he was dependent on staff for transfers and ambulation. On 05/20/2025 at 10:19 a.m., an observation was made of Resident #60's call light to be lit up. At 10:32 a.m., S17CNA was observed entering Resident #60's room. She told the resident once she got finished with the resident she was working with, she would find someone to help her get him back in bed because he required two people. On 05/20/2025 at 10:37 a.m., an observation was made of S17CNA coming out of another resident's room stating this is too much. She grabbed supplies from off the supply cart then went back into the room. On 05/20/2025 at 11:32 a.m., an interview was conducted with Resident #60. He stated he was mad and had been waiting an hour and a half for S17CNA to put him back to bed. He stated S17CNA told him she was waiting on someone to come help her get him back to bed, but she had not come back yet. On 05/20/2025 at 11:36 a.m., an observation was made of two CNA's assisting Resident #60 back to bed. On 05/20/2025 at 10:50 a.m., an interview was conducted with S17CNA. She stated there was 1 CNA who was assigned to Hall B. She stated it had been 2 months since there had been a second CNA assigned to Hall B. She stated there were 5 residents who needed hoyer lifts so she needed an extra staff member to get those residents out of bed and back to bed. She stated the residents got frustrated with her at times because she was not able to respond to the call light and assist them in a timely manner. She stated there were 13 residents down Hall B she was assigned to, and 4 more down another hall which she was assigned to. She stated she was assigned to 17 resident's total. She confirmed Resident #6 notified her she had a bowel movement and needed changing when she went into her room at 8:55 a.m., and confirmed it was almost an hour later before she was able to change her. She stated Resident #31 was confused and unable to do anything for herself. She confirmed it was now 11:05 a.m., and she had not been in Resident #31's room since 8:00 a.m. She stated Resident #60 put his call light on to get back in bed. She confirmed he had to wait over an hour to be put back to bed because she had to wait on another staff member to help her since he required a hoyer lift transfer. She stated she had notified administrative staff she needed help, but she was told the census was low and Hall B only required 1 CNA. She stated she was unable to complete her rounds every 2 hours and answer call lights in a timely manner with her being the only CNA on Hall B. On 05/20/2025 at 11:38 a.m., an interview was conducted with S15PTA. She stated she frequently was asked to help the CNA on Hall B turn residents and get them out of bed because there was only 1 CNA assigned to the hall. On 05/20/2025 at 1:01 p.m., an interview was conducted with S4ADON. She stated she was responsible for staff scheduling. She stated the number of staff required on each hall depended on the census. She stated the CNA scheduled on Hall B had all the residents on that hall and 4 residents from another hall. She stated those halls were heavy for a while, so there were 2 CNA's assigned, but now those halls were light so there was 1 CNA on the halls. She stated today there were 7 CNA's, including the bath aid, for the whole building for the 6:00 a.m.-2:00 p.m. shift. She was notified of the above observations. She stated 15-20 minutes was the most a resident should wait to be changed if soiled. She stated 1.5 hours was not an acceptable time for a resident to have to wait to be put back to bed upon request. She stated based on the observations told to her, Hall B did not have sufficient staff to meet the needs of the residents. She stated the acuity of the residents was not taken into account as it should have been. She stated the average resident to CNA ratio was 1:15. 2. Resident #32 Review of Resident #32's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses with included Presence of Cardiac and Vascular Implant and Graft, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of Resident #32's Admission MDS with an ARD of 03/10/2025 revealed a BIMS of 12, which indicated she was moderately cognitively impaired. Review of Resident #32's Current Physician Orders revealed the following, in part: Dialysis every Monday, Wednesday, Friday Review of Resident #32's MAR dated May 2025 revealed the following, in part: 05/19/2025- Checked that Resident #32 went to dialysis, initialed by S7LPN Review of Resident #32's Nurse's Notes revealed the following, in part: 05/19/2025-Resident requested to not go to dialysis today, stated she does not feel well. Signed by S11LPN. On 05/19/2025 at 8:26 a.m., an interview was conducted with Resident #32. She stated she went to dialysis on Mondays, Wednesdays, and Fridays. She stated she usually left the facility at 11:45 a.m. and returned around 4:15 p.m. She stated she was not feeling well today and was not going to go. On 05/19/2025 at 3:15 p.m., an interview and observation was conducted of Resident #32. She was in the dining room sitting in her wheelchair. She confirmed she refused dialysis today. On 05/20/2025 at 2:32 p.m., an interview was conducted with S7LPN. She confirmed she was assigned to Resident #32 on 05/19/2025. She stated she did not know if Resident #32 went to dialysis yesterday. She stated she was assigned to 32 residents on her shift. She stated, I was pulled in a thousand directions yesterday. She stated she assumed Resident #32 went to dialysis because she didn't get told by the CNA that she refused to go. She stated if Resident #32 refused to go to dialysis, she should have documented the refusal on the MAR, made a nurses note, and called the dialysis clinic to notify them. On 05/20/2025 at 2:48 p.m., an interview was conducted with a staff member from Resident #32's Dialysis Center. She stated Resident #32 did not show up to dialysis yesterday. She stated the clinic called the facility and was notified Resident #32 was not going to dialysis because she was not feeling well. On 05/21/2025 at 2:45 p.m., an interview was conducted with S1ADM. She stated staffing was determined by census. She was made aware of the staffing observations on 05/19/2025. She stated she did not expect a resident to stay soiled for 51 minutes before being changed. She stated CNA's should make rounds every 2 hours, and residents should be assisted back to bed timely. She was notified of S7LPN not being aware Resident #32 refused dialysis on 05/19/2025 because she stated she was pulled in a thousand directions. She stated it was an issue if the nurse did not know her resident refused dialysis and was at the facility for 3-4 hours, when she thought she was out of the facility.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was properly stored in the walk-in cooler and walk-in freezer; 2. Food was properly stored in the dry food storage room; 3. Dietary employees wore effective hair restraints while engaged in the handling and preparation of food; 4. Ceiling vents in the kitchen were properly cleaned and free of black and grey substances; and 5. Meals carts were properly cleaned and free of debris. This deficient practice had the potential to affect the 79 residents who were served food from the kitchen. Findings: Review of the facility's policy titled, Storage of Refrigerated Food with a revision date of 10/2018, revealed the following, in part: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. All non-hazardous, open foods are labeled with name of food and date stored. All hazardous foods are labeled with name of food and date to be discarded or the date stored. On 05/18/2025 at 8:10 a.m., an initial tour was made of the kitchen with S9CK. The following observations were made: Walk-in cooler: One box of cucumbers with a packaged date of 04/25/2025, containing 10 cucumbers, with 5 noted with a grey and green, fuzzy, round substance attached to them, and; One clear plastic bag containing six heads of lettuce with one head noted to have an approximately 1.5 inch by 1.5 inch dark brown spot with dark brown juice on the head and inside the bag. Walk-in freezer: One clear plastic bag containing five round meat patties, unsealed, not labeled or dated, and; One brown box containing mixed vegetables, unsealed and undated. Dry storage room: One opened five pound bag of yellow cake mix, unsealed and not dated, Ten sixteen ounce bags of marshmallows with a best if used by date of 04/01/2025, One clear square container of a white powdery substance, unsealed, not labeled or dated, and; Two clear square containers containing breakfast cereal, unsealed, not labeled or dated. On 05/18/2025 at 8:35 a.m., an observation was made of S9CK preparing and cooking food for the lunch service. Approximately two to three inches of S9CK's hair was not contained in her hairnet. On 05/18/2025 at 08:50 a.m., an interview was conducted with S9CK. She confirmed the above mentioned items were not sealed, labeled, or dated and should have been. She confirmed the cucumbers and bag of lettuce were spoiled and should have been discarded. She further confirmed her hair should be completely contained inside the hairnet while preparing or cooking food. S9CK was observed during the interview to place her uncontained hair into the hairnet without issue. On 05/18/2025 at 09:47 a.m., an interview was conducted with S8DM. She was made aware of the above findings. She confirmed all food items should be properly sealed, dated, and labeled and discarded if spoiled. She further confirmed all dietary employees' hair should be contained inside of their hairnets during food preparation and cooking. On 05/18/2025 at 11:30 a.m., a follow-up visit was made of the kitchen with S8DM. The following observations were made: The ceiling and vent above the dishwasher was observed with a moderate amount of a fluffy grey substance; The ceiling vent above the three compartment sink was observed with a moderate amount of a fluffy grey substance; and The ceiling vent located near the steam table was observed with a moderate amount of a fluffy grey and black substance with an approximate six inch string of a fluffy grey substance hanging. On 05/18/2025 at 12:00 p.m., an interview was conducted with S8DM. She observed and confirmed the above mentioned findings. She stated the kitchen's ceiling vents had dust on them and needed to be cleaned. On 05/18/2025, at 12:05 p.m., an observation was made of one enclosed meal cart brought into the kitchen by S8DM. A microwave was observed secured to the top of the enclosed meal cart and was placed at the end of the food line for loading by S8DM. The top of the enclosed meal cart and microwave were noted to be unclean with food debris and dried substances. Four additional enclosed meal carts with microwaves were observed with S8DM and were noted to be soiled with food debris and dried substances on the top of the carts and inside and outside of the microwaves. On 05/18/2025 at 12:08 p.m., an interview was conducted with S8DM. She stated kitchen staff were responsible for cleaning the enclosed meal carts and microwaves after each meal service. She confirmed the 5 enclosed meal carts and microwaves were not clean and should have been. 52121

Based on observations, interviews, and record reviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. Nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 2 (#19 and #69) of 3 (#19, #69, and #391) residents reviewed for insulin administration; and 2. Nursing staff donned proper Personal Protective Equipment (PPE) during direct resident care for 2 of 2 (#1 and #76) residents whom required EBP (Enhanced Barrier Precautions). Findings: Review of the facility's policy titled, Infection Prevention and Control Program, with an effective date of 09/30/2022, revealed the following, in part: Purpose: The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention and Control of Transmission of Infection: The facility's infection control practices are important to preventing the transmission of infections. Infection control precautions used by the facility include two primary tiers: Standard Precautions . 1. Standard Precautions B. Standard precautions include but are not limited to safe injection practices . 1. Review of the Humalog Kwik pen Manufacturer's Insert revealed the following, in part: Preparing your Pen: Step 1: Pull the Pen Cap straight off. Wipe the Rubber Seal with an alcohol swab. Step 2: Pull off the Paper Tab from Outer Needle Shield. Step 3: Push the capped Needle straight onto the Pen and turn the Needle forward until it is tight. Resident #19 Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #19's current Physician Orders revealed the following, in part: Order date: 01/28/2025 Humalog Kwik Pen 100 unit/ml, inject per sliding scale, subcutaneously before meals and at bedtime. On 05/19/2025 at 11:18 a.m., an observation was made of S6LPN administering Resident #19's Humalog insulin. S6LPN removed Resident #19's Humalog insulin pen cap and attached the insulin pen needle without sanitizing the insulin pen stopper. S6LPN administered Resident #19's insulin. On 05/19/2025 at 11:20 a.m., an interview was conducted with S6LPN. She confirmed she did not sanitize Resident #19's insulin pen stopper prior to applying the insulin pen needle. Resident #69 Review of Resident #69's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus with Ketoacidosis with Coma. Review of Resident #69's current Physician Orders revealed the following, in part: Order date: 03/26/2025 Humalog Injection Solution 100 unit/ml, inject per sliding scale, subcutaneously with meals. On 05/19/2025 at 8:45 a.m., an observation was made of S7LPN administering Resident #69's Humalog insulin. S7LPN removed Resident #69's Humalog insulin pen cap and attached the insulin pen needle without sanitizing the insulin pen stopper. S7LPN administered Resident #69's insulin. On 05/19/2025 at 8:47 a.m., an interview was conducted with S7LPN. She confirmed she did not sanitize Resident #69's insulin pen stopper prior to applying the insulin pen needle. On 05/19/2025 at 1:47 p.m., an interview was conducted with S2RNSUP. She confirmed all insulin pen stoppers should have been sanitized prior to applying the insulin pen needle. 2. Review of the facility's policy titled, Enhanced Barrier Precautions Policy and Procedure , with an effective date of 04/01/2024, revealed the following, in part: Purpose: To prevent the spread of potential infection by implementing Enhanced Barrier Precautions (EBP) when contact precautions do not apply. This approach recommends the use of EBP during high contact care activities for residents with chronic wounds or indwelling devices. Procedure: 1. EBP are indicated for residents' with any of the following: b. Wounds and/or indwelling devices even if the resident is not known to be infected. 4. For residents for whom EBP are indicated. EBP is employed when performing the following high contact resident care activities: g. Device care or use (urinary catheter) h. Chronic Wound care Resident #1 Review of Resident #1's Clinical Record revealed he was admitted on [DATE] with diagnoses, which included Overactive Bladder, Neuromuscular Dysfunction of Bladder, and Artificial Opening of Urinary Tract. Review of Resident #1's Physician Orders revealed the following, in part: Order date: 01/28/2025 Enhanced Barrier Precautions: utilize gown and gloves during high-contact care activities for resident's with chronic wounds or indwelling medical devices every shift related to Other Artificial Openings Of Urinary Tract Status. Review of Resident #1's Care plan dated 04/30/2025 revealed the following, in part: Revision date 05/20/2025 Problem: Chronic wounds, colostomy, and Suprapubic Catheter that warrants Enhanced Barrier Precautions. Interventions: Utilize gloves and gown when performing high contact resident care activities, gown when providing care to medical devices (urinary catheter). On 05/19/2025 at 04:50 p.m., an observation was made of S3ADON performing catheter care and dressing change on Resident #1. S3ADON gathered supplies outside of resident's room with visible EBP signage posted on outside of door. S3ADON performed hand hygiene, put on gloves and proceeded to enter room. S3ADON did not apply a gown prior to entering room, removing old dressing, or prior to performing catheter care on Resident #1. On 05/20/25 at 03:10 p.m., an interview was conducted with S3ADON. She confirmed she did not apply appropriate PPE prior to performing catheter site care and dressing change on Resident #1's indwelling suprapubic urinary catheter. S3ADON further confirmed there was appropriate signage on outside of door for EBP. She confirmed she should have donned a gown prior to providing direct care of urinary catheter device and she had not. Resident #76 Review of Resident #76's clinical record revealed an admitted [DATE] with diagnoses, which included Non-Pressure Chronic Ulcer Left Foot, Pressure Ulcer of Sacral Region, and Pressure Ulcer Left Heel Stage 3. Review of Resident #76's Physician Orders revealed the following: Order Date- 08/14/2024- Enhanced Barrier Precautions: utilize gown and gloves during high contact care activities for Residents with chronic wounds or indwelling devices. On 05/19/2025 at 4:30 p.m., an observation was made of S3ADON performing wound care to Resident #76 wounds. S3ADON gathered supplies outside of resident's room with visible EBP signage posted on outside of door. S3ADON proceeded by entering room, performed hand hygiene and applied gloves. S3ADON failed to adhere to Enhanced Barrier Precautions and apply a gown prior to providing direct care to wounds. On 05/20/2025 at 3:10 p.m., an interview was conducted with S3ADON. She stated Resident #76 was on EBP related to wounds and currently had an indwelling device in place. She confirmed she failed to apply gown prior to providing direct care to Resident #76's wounds and should have. On 05/21/2025 at 9:25 a.m., an interview was conducted with S2RNSUP. She was made aware of the above findings. She stated she expected staff to properly don PPE when a resident is on EBP. S2RNSUP confirmed staff were required to don gown and gloves when performing wound care and catheter care. S2RNSUP confirmed EBP should have been followed prior to providing direct care to wounds and catheter care. 47191 52121

47191 Based on record review and interview the facility failed to complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 2 of 20(#6 and #29) sampled resident's. Findings: Resident #6 Review of Resident #6's Significant Change MDS with an ARD of 03/06/2025 revealed an admitted [DATE]. Further Review of Resident #6's Significant Change MDS with an ARD of 03/06/2025 revealed assessment was completed on 03/26/2025. Resident #29 Review of Resident #29's Significant Change MDS with an ARD of 05/05/2025 revealed an admitted [DATE]. Further review of Resident #29's clinical record revealed a Significant Change MDS with an ARD of 05/05/2025 with a submission status of in progress. On 05/21/2025 at 12:56 p.m. an interview was conducted with S13MDS. She reviewed Resident #6 and Resident #29 most recent significant change assessments. S13MDS confirmed Resident #6 Significant Change assessment dated [DATE] was not completed within required timeframe. S13MDS confirmed Resident #29 Significant Change assessment dated [DATE] was still in progress and assessment was not completed within required timeframe. S13MDS confirmed Resident #6 and Resident #29 significant change assessments should have been completed within 14 days and were not. On 05/21/2025 at 2:10 p.m. an interview was conducted with S2RNSUP. She reviewed Resident #6 and Resident #29 most recent significant change assessments. S2RNSUP confirmed Resident #6 Significant Change assessment dated [DATE] was not completed within required timeframe. S2RNSUP confirmed Resident #29 Significant Change assessment dated [DATE] was still in progress and assessment was not completed within required timeframe. S2RNSUP confirmed Resident #6 and Resident #29 significant change assessments should have been completed within 14 days and were not.

Based on record review and interview the facility failed to ensure a baseline care plan was developed within 48 hours of admission to the facility for 1 (#290) of 20 sampled residents. Findings: Review of Resident #290's medical record revealed an admitted [DATE] with diagnoses which included Type II Diabetes Mellitus, Atrial Fibrillation and Major Depressive Disorder. Review of Resident #290's medical record revealed a baseline care plan was initiated on 05/19/2025. On 05/21/2025 at 12:56 p.m. an interview was conducted with S19MDS. She reviewed Resident #290's care plan and confirmed she initiated it on 05/19/2025. S19MDS confirmed baseline care plans should be implemented within 48 hours of admission and Resident #290's was not. On 05/21/2025 at 2:10 p.m. an interview was conducted with S2RNSUP. She reviewed Resident #290's baseline care plan and confirmed it was initiated on 05/19/2025. S2RNSUP confirmed she would expect all residents to have a baseline care plan within 48 hours of Admission. S2RNSUP confirmed Resident #290's baseline care was not implemented in a timely manner and should have been.

Based on interviews and record review, the facility failed to ensure residents who required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for 1 (#240) of 2 (#37 and #240) residents reviewed for ADLs. Findings: Review of the facility's policy titled Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Policy: Bed Baths are to be given as scheduled and/or as needed. Review of Resident #240's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Complete Traumatic Amputation of Left Foot and Fracture of Right Shoulder. Review of Resident #240's Admission MDS with an ARD of 05/10/2025 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further reviewed revealed he was dependent on staff for bathing/showering. Review of Resident #240's Nurses Notes dated 05/06/2025 - 05/20/2025 revealed no documentation of Resident #240 refusing baths or showers. Review of Resident #240's Shower Logs dated May 2025 revealed his bath/shower days were Tuesdays, Thursdays, and Saturdays. Further review revealed the following, in part: Shower/Bath Task: 05/06/2025-5/14/2025 - blank 05/15/2025 - charted refused 05/16/2025 - 5/20/2025 - blank On 5/20/2025 at 8:31 a.m., an interview was conducted with Resident #240. He stated he had only received 1 bath since being admitted to the facility. He stated he had multiple fractures and was unable to give himself a bath. He stated he had visitors one day when the CNA came in to give him a bath, and he asked the CNA to come back later if she could. He stated no one ever came back and he had not refused any other baths. On 5/20/2025 at 10:50 a.m., an interview was conducted with S17CNA. She stated she was working 6:00 a.m.-2:00 p.m. today, but usually worked the 2:00 p.m.-10:00 p.m. shift. She stated the shower aids on the halls were responsible for giving the resident's baths/showers. She stated when the shower aid was pulled to the floor, the floor CNA would try to get baths completed if possible. She stated she had never given Resident #240 a bath/shower. On 05/20/2025 at 1:51 p.m., an interview was conducted with S18SA. She stated she was scheduled Monday-Friday from 6:00 a.m.-2:00 p.m. as the shower aid. She stated she got pulled to the floor usually 3 days a week. She stated when she was pulled, if she did not volunteer to stay until the next shift and bathe/shower residents, staff would attempt to call someone in, if not, residents would not get a bath. She stated she was responsible for bathing/showering the residents on Hall B. She stated Resident #240 required a bed bath because he could not stand on his own to get in the shower. She stated his bath days were Tuesdays, Thursdays, and Saturdays. She reviewed Resident #240's bath flowsheet dated May 2025 and confirmed since he was admitted , no baths had been documented. She stated she wiped him off the day after he was admitted , but had not given him a bath since then. On 05/21/2025 at 9:04 a.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #240 from 6:00 a.m.-2:00 p.m. She stated the shower aid completed Resident #240's baths. She stated on days like today, when they were short staffed and pulled the shower aid to work the floor, the floor CNA was responsible for giving baths/showers. She stated she had never given Resident #240 a bath since he had been admitted . She reviewed Resident #240's bathing flowsheet and verified he was admitted on [DATE] and there had been no baths charted as being given, and only 1 refusal charted on 05/15/2025. On 05/21/2025 at 2:45 p.m., an interview was completed with S1ADM and S2RNSUP. S1ADM reviewed Resident #240's bathing flowsheet and confirmed no baths had been documented as given since he was admitted , and only 1 refusal had been documented. S2RNSUP stated she had 2 CNA's bathe Resident #240 on Saturday 05/17/2025 so she knew he received a bath that day. S1ADM and S2RNSUP were unable to confirm Resident #240 received a bath before 05/17/2025. They stated any refusals or baths given should have been documented.

Based on interviews and record reviews, the facility failed to provide wound care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#240) of 3 (#19, #76, #240) sampled residents reviewed for wound care. Findings: Review of facility's Dressing Change (Wound Care), Clean Policy and Procedure policy dated 10/30/2024 revealed, in part: Policy Complete dressing changes as ordered by the physician. Review of Resident #240's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Complete Traumatic Amputation of Left Foot and Fracture of Right Shoulder. Review of Resident #240's Admission MDS with an ARD of 05/10/2025 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #240's current Care Plan revealed the following, in part: Problems: Laceration to left knee, Laceration to right forearm, Surgical incision related to left below knee amputation (LBKA), Abrasion to left knee, Abrasion to right great toe Interventions: The resident is receiving treatment per MD orders Review of Resident #240's current Physician Orders revealed the following, in part -Abrasion to left knee. Clean with wound cleanser, pat dry, apply triple antibiotic ointment (TAO) and cover with clean dry dressing of choice until resolved one time a day. -Abrasion to right great toe. Cleanse with wound cleanser, pat dry, apply TAO and cover with clean dry dressing of choice until resolved one time a day. -Laceration to left knee. Cleanse with wound cleanser, pat dry, and cover with clean dry dressing until resolved one time a day. -Laceration to right forearm. Cleanse with wound cleanser, pat dry, and cover with clean dry dressing until resolved one time a day. -Surgical incision to left below knee amputation (LBKA). Clean with wound cleanser, pat dry, apply betadine and cover with clean dry dressing until resolved one time a day. Review of Resident #240's TAR dated May 2025 revealed no documentation the following wound care was provided on 05/09/2025: Abrasion to left knee, abrasion to right great toe, laceration to left knee, laceration to right forearm, and surgical incision to LBKA. Review of Resident #240's Nurse's Note revealed no documentation regarding a refusal or why wound care was not completed on 05/09/2025. On 05/20/2025 at 8:31 a.m., an interview was conducted with Resident #240. He stated he was supposed to receive wound care daily. He stated he could not recall specific days, but there had been days where he did not receive wound care. On 05/21/2025 at 10:00 a.m., an interview was conducted with S12TN. She stated she worked Monday-Friday as the wound care nurse. She stated when she was pulled to the floor or was unavailable, one of the ADON's would complete wound care. She stated Resident #240 had dressing changes ordered daily. She stated on 05/09/2025 she had a doctor's appointment at noon and left early. She stated she did not perform Resident #240's wound care treatments and notified S4ADON she was unable to complete them. On 05/21/2025 at 12:28 p.m., an interview was conducted with S4ADON. She stated she was notified S12TN left early on 05/09/2025 and did not complete Resident #240's wound care. She stated Resident #240 had a lot of pain that day and she notified S14NP. She stated S14NP said it was ok to hold the dressing change for 05/09/2025. She stated she did not chart his wound care treatment was held on 05/09/2025 and should have. On 05/21/2025 at 2:07 p.m., an interview was conducted with S14NP. She stated she was not notified on any day since Resident #240's admission that he was in too much pain to receive wound care treatment, or gave an order for wound care to be held. She stated she expected staff to provide wound care to Resident #240 daily as ordered. On 05/21/2025 at 2:45 p.m., an interview was completed with S1ADM. She reviewed Resident #240's TAR for May 2025 and verified the wound care for 05/09/2025 was not documented as completed. She confirmed wound care treatments should be completed per doctor orders, unless a resident was in too much pain. She further confirmed if wound care was not completed because a resident was in pain, it should be documented.

Based on interviews and record review, the facility failed to ensure residents were free of significant medication errors for 1(#78) of 33 residents reviewed in the final sample. The facility failed to ensure Resident #78 received Eliquis as ordered by the physician. This deficient practice resulted in an Immediate Jeopardy situation for Resident #78, a resident with a history of Pulmonary Embolism and Acute Embolism and Thrombus of the Lower Extremity, on [DATE] at 08:00 a.m. when S5LPN discontinued his order for Eliquis without a physician's order. Resident #78 did not receive Eliquis as ordered from [DATE] through [DATE]. Resident #78 was found on [DATE] at 12:00 a.m., lying on the right side of the floor, unresponsive, pulseless and not breathing. The coroner's report read causes of death: Acute Myocardial Infarction vs Pulmonary Embolism; Hypertension' changes of Aging. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. S1NFA and S2DON were notified of the Past Noncompliance Immediate Jeopardy on [DATE] at 3:38 p.m. Findings: Review of the medication Black Box Warning for Eliquis revealed the following, in part: Warning: Premature discontinuation of Eliquis increases the risk of thrombotic events: Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic events. To reduce this risk, consider coverage with another anticoagulant if Eliquis is discontinued for a reason other than Pathological bleeding or completion of a course of therapy. Eliquis is indicated for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following initial therapy. Review of the clinical record revealed Resident #78 was admitted to the facility [DATE] with diagnoses which included, Acute Embolism and Thrombosis of Right Distal Lower Extremity and Pulmonary Embolism without Acute cor Pulmonale. Review of the Care Plan dated [DATE] for Resident #78 revealed the following, in part: Problem: I am at risk for deep vein thrombosis. Interventions: Administer my anticoagulant as ordered . Review of the Hospital Discharge orders, dated [DATE] revealed in part, the following: Eliquis 5 mg tablet for a clot in the lung, take 2 tablets by mouth 2 times daily for 30 days, then 1 tablet (5 mg total) 2 times daily on [DATE]. Review of the Physician Orders dated [DATE] for Resident #78 revealed on [DATE] at 8:00 p.m. an order was implemented for Eliquis 5 mg tablet by mouth twice daily and on [DATE], the Eliquis was discontinued. Further review revealed no order to discontinue Eliquis 5 mg tablet by mouth twice daily. Review of the Medication Administration Record dated [DATE] for Resident #78 revealed Eliquis 5 mg tablet by mouth twice daily was not on the MAR to be administered from [DATE] to [DATE] per physician orders. Review of the nurse's note dated [DATE] revealed the following: [DATE] at 12:00 a.m.: Summons to room by CNA when arrived observed resident lying on right side on floor nonresponsive. No pulse, no breathing noted. Charge nurse verified code status as DNR. Notified Acadian who came out and did an EKG which showed asystole. Acadian paramedics advised to leave body on floor until coroner review body. Review of the Coroner's Report for Resident #78 revealed the following, in part: I, Coroner, certify the following report of death: Date and time of death: [DATE] at 00:15 Causes of death: Acute Myocardial Infarction vs Pulmonary Embolism; Hypertension' changes of Aging. On [DATE] at 10:21 a.m., a telephone interview was conducted with S14NP. She stated she would not discontinue Resident #78's Eliquis due to his history of Pulmonary Embolism and an active blood clot. She stated Resident #78 not receiving the Eliquis for ten days could have contributed to his death. She stated Resident #78 did not have any procedures that would have caused a physician to hold the Eliquis for a period of time. On [DATE] at 10:35 a.m., an interview was conducted with S2DON. She stated Resident #78 had a history of a cerebrovascular accident, traumatic brain injury, and was admitted to the facility in [DATE] with a blood clot. She stated S5LPN discontinued Resident #78's Eliquis on [DATE] without a physician's order. On [DATE] at 12:36 p.m., a telephone interview was conducted with S5LPN. She confirmed she discontinued Resident #78's Eliquis, but did not know why. She stated she believed Resident #78 had an upcoming procedure and that was why she discontinued the Eliquis. On [DATE] at 12:45 p.m., an interview was conducted with S2DON. She stated when a medication order was modified or discontinued the nurse should document a note in the electronic chart stating who discontinued or modified the medication and why. She reviewed Resident #78's clinical record and confirmed there was no documentation or order to discontinue Eliquis. She stated if there was no order to discontinue Resident #78's Eliquis, then the medication should not have been stopped. She confirmed S5LPN discontinued Resident #78's Eliquis on [DATE] without a physician's order. She confirmed Eliquis was removed from the MAR on [DATE] after the order was discontinued and there was no documentation Resident #78 received the medication from [DATE] through [DATE] when Resident #78 expired. On [DATE] at 5:20 p.m., an interview was conducted with S13LPN. She explained S2DON or the floor nurse would place orders in the resident's chart and then initiate the order in the electronic system. She stated each day she would review the telephone order slips or order discontinuation forms from the previous day to ensure the orders were implemented accurately. She confirmed if there was not an order to discontinue a medication, she would not have known to review it for accuracy. She reviewed Resident #78's physician's orders and confirmed Eliquis 5 mg twice a day was discontinued on [DATE] at 3:52 p.m., by S5LPN, without a physician's order. S13LPN stated beginning the last week of each month, administrative staff should print reports and verify all orders in the resident's charts were accurate. She stated the facility would not have known Resident #78's Eliquis was discontinued without an order until the end of the month of [DATE]. She confirmed the facility did not include Resident #78's chart check in the [DATE] review because he had already expired. She stated she received in-service training on the new chart check process and verifying order entry and discontinuation during the end of [DATE] through May because the facility switched of computer systems. On [DATE] at 11:00 a.m., an interview was conducted with S2DON. She stated she was not aware Resident #78's Eliquis was discontinued without a physician's order until yesterday. She stated the facility implemented a new computer system on [DATE]. She stated with the implementation of the new system, the facility implemented corrective actions to ensure orders accuracy. She stated the new process was all current resident's orders would be verified against written orders and checked for accuracy. She stated all nursing staff were in-serviced on order entry and discontinuation in the new computer system on [DATE]. She stated on [DATE], after surveyors entered the facility, nursing staff compared the resident's paper MARs to the orders in the new computer system and to the Medication Card instructions during med passes to ensure proper administration of medications as ordered. She stated since [DATE], each morning, Data Entry compared carbon copies of new written orders and a report of newly discontinued orders generated from the computer data to ensure residents received medications as ordered. She stated the facility reeducated nurses on the importance of entering medication orders into the electronic record and comparing the medication cards to the eMAR during med pass for order accuracy on [DATE]. She stated going forward the facility will have e-signature available for physician use to sign orders. She stated on [DATE] education and ongoing completion of order validation began and continues to date with no issues identified. S2DON read the written plan of removal, which stated substantial compliance was attained and maintained effective [DATE]. She stated the facility was in complete compliance on [DATE]. The facility has implemented the following actions to correct the deficient practice: On [DATE] the following plan of correction was completed and included the following: Issue/Concern: Administer anticoagulant medications as ordered. (J.[NAME] documentation of Eliquis being administered as ordered incomplete per review of the MAR beginning [DATE]- [DATE]) Areas/Systems/Programs Affected: - On admission a data entry error into computer system Physician's Order module for Eliquis frequency and a D/C of Eliquis on [DATE] resulted in prior non-compliance for no or inaccurate electronic documentation of administration of Eliquis to J. [NAME]. - An audit of Eliquis supply ordered and obtained from Pharmacy from [DATE] - [DATE] compared to remaining supply of Eliquis indicates facility provided the 140 tabs required to administer Eliquis as ordered during facility stay ([DATE] - [DATE]). Plan of Correction: The following tasks/ methods were completed in to ensure medications administered as ordered by the facility: 1. Administrative nursing staff were trained by the new computer system liaison on order entry including discontinued orders on [DATE] with competencies dated [DATE]. 2. From [DATE] - [DATE], Data Entry nurse reviewed current and newly received orders in computer system for accuracy and no issues were noted. 3. From [DATE] - [DATE], data entry nurse completed audits of carbon copies of newly written orders including newly discontinued orders to ensure current medications ordered are firing properly ensure proper administration of medications. 4. Facility completed chart audits of current resident's physician's orders and compared them to orders entered into computer system electronic order module [DATE] to [DATE] to ensure current medications ordered are firing properly in the eMAR for order validation to ensure proper administration of medications as ordered. Reviewing nurse signed/dated [DATE]'s monthly physician's orders and they were sent to MD for review and signature then filed on resident's chart. 5. Administrative nurses and Regional QI nurses trained staff nurses on order entry including discontinuing orders on [DATE]. 6. On [DATE], facility again completed chart audits of current resident's physician's orders and compared the orders in prior computer system to ensure current medications ordered are firing properly in eMAR for order validation to ensure proper administration of medications as ordered. Reviewing nurse signed/dated [DATE]'s monthly physician's orders and they were sent to MD for review and signature then filed on resident's chart. 7. On [DATE], data migration of orders from the prior computer system into the new system completed. 8. From [DATE] to [DATE], Facility dual entered newly written orders including newly discontinued orders into both computer systems to ensure current medications ordered fired properly in eMAR for order validation to ensure proper administration of medications as ordered. 9. From [DATE] to [DATE], facility completed chart audits of current resident's physician's orders, newly received orders, and newly discontinued orders compared to orders entered into the new system and the prior system's electronic orders module to ensure current medications ordered fired properly in eMAR for order validation to ensure prop administration of medications as ordered. 10. On [DATE], nursing staff compared prior system paper MARs/TARs to new system eMAR/eTAR to Medication Card instructions during med passes for order validation to ensure proper administration of medications as ordered. 11. Since [DATE], each morning, Data Entry has compared carbon copies of newly written orders and a report of newly discontinued orders generated from the new system data validation to ensure residents continued to receive medications as ordered. 12. On [DATE], Data Entry re-validated newly entered and newly discontinued orders in the new system to ensure medications are firing to system's eMAR properly from [DATE] - [DATE] for proper documentation of administration as ordered with no issues noted. 13. The following steps will be completed for order validation to ensure proper administration of medications as ordered: - Data entry of medication orders for new admissions will be confirmed by 2 nurses - Monday - Friday, Data Entry or designee will compare carbon copies of newly written orders and a report of newly discontinued orders generated from the new system to the current orders in the system - These carbon copies of newly received orders and reports of newly discontinued orders will be retained to be reviewed again during end of month order validation 14. [DATE], Data Entry re-educated by the DON on the order validation process to ensure administration of medications as ordered. 15. On [DATE], facility re-educated nurses by ADON on the importance of entering medications orders into the new system and comparing the medication cards to the eMAR during med pass for order validation to ensure proper administration of medications as ordered. 16. Going forward facility will have e-signature available for physician use to sign orders and the facility does not currently use agency staff and has not used them since the last day in [DATE]. There is no plan to reinstitute agency staff at this time. 17. The DON or designee will monitor by reviewing completion of order validation findings twice weekly on a random sample of 10 residents to ensure continued compliance for 6 weeks and randomly monthly thereafter. 18. All new nursing staff will be trained by staff development nurse or designee on administering medication as ordered during orientation prior to independent medication administration. 19. On [DATE] education and ongoing completion of order validation began and continues to date with no issues identified, it is the facilities belief that substantial compliance was attained and maintained effective [DATE].