Every finding on record at Homestead Hills

Based on observations, record reviews, and staff, Nurse Practitioner (NP), Pharmacist, and Medical Director interviews, the facility failed to have effective systems in place to prevent a significant medication error. Resident #4 was severely cognitively impaired and had a diagnosis of sinus bradycardia (slow heart rate). On 3/11/2026 the Medication Aide (MA) administered morning medications to Resident #4 which included extended-release propranolol (a betablocker used to treat hypertension which slows the heart rate, reduces the force of heart contractions, and lowers blood pressure), quetiapine (antipsychotic medication that can cause sudden drops in blood pressure) and donepezil. Donepezil can slow the heart rate and affect the sinoatrial (SA) node and atrioventricular (AV) nodes, potentially leading to bradycardia or heart block which is a disruption in the electrical signals that regulate heartbeat. (The SA node set the heart's rate and rhythm, and the AV node regulates the timing of ventricular contractions). The Medication Aide returned to the medication cart and prepared Resident #47's medications and proceeded to administer these to Resident #4. The medications included metoprolol succinate extended release (a betablocker used to treat hypertension that slows the heart rate and lowers blood pressure), tamsulosin (an alpha-blocker used to treat symptoms of enlarged prostate which can cause low blood pressure), and amlodipine (a calcium channel blocker used to treat hypertension and chest pain that lowers blood pressure by causing blood vessels to relax and widen throughout the body), and donepezil. Approximately 30 minutes later the Medication Aide realized he had administered medications prescribed for Resident #47 to Resident #4 and reported this to the nurse immediately. Resident #4 was assessed by the nurse and NP, was lethargic, and his heart rate was in the 40's range and dropped into the high 30's with a blood pressure (BP) reading of 90/60. (The normal range for heart rate is 60 to 100 beats per minute (bpm)). Emergency Medical Services (EMS) was contacted and transported Resident #4 to the hospital for evaluation and treatment. The physician documented the principal problem was severe symptomatic bradycardia and hypotension (low blood pressure) secondary to an unintentional medication overdose with betablockers and amlodipine. The resident received epinephrine drip (a continuous intravenous infusion used to support blood pressure, heart function and bronchodilation in critical situations) and atropine (anticholinergic medication used to treat bradycardia) for his low heart rate. Blood pressures improved and his heart rate was in the mid 40's. The plan was to continue the epinephrine drip and transfer the resident to the Critical Care Unit (CCU) for monitoring. Initial management included epinephrine infusion and atropine with limited response which suggested a high degree heart block (a high-degree heart block is a serious form of AV block where the electrical signals from the atria to the ventricles are significantly impaired). Resident #4's hospital electrocardiogram (ECG) results (An ECG checks the heartbeat and electrical signals in the heart and can help diagnose heart attacks and irregular heartbeats, called arrhythmias) showed progression from sinus bradycardia with a second-degree AV block (second-degree heart block, also known as second-degree AV block, is characterized by the intermittent failure of atrial impulses to conduct to the ventricles) to a complete heart block (complete heart block is a serious condition where electrical signals from the atria fail to reach the ventricles, often requiring urgent medical intervention). On 3/13/26 Resident #4 was implanted with dual-chamber pacemaker (A dual chamber pacemaker regulates both the atrium and ventricle to maintain synchronized heartbeats and optimize cardiac efficiency). The resident's clinical status improved, and he was discharged back to the facility on 3/16/26. Resident #4 had a serious adverse outcome as a result of the medication error. The deficient practice occurred for 1 of 5 residents reviewed for significant medication errors (Resident #4).Finding included:Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Type II diabetes mellitus (DM), depression, hypertension, sinus bradycardia (2/28/25), and psychotic disorder with hallucinations due to known physiological condition. On 01/28/2026, Resident #4 was transitioned to Hospice services. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired, independent with eating and required maximum assistance for activities of daily living (ADL) and used a wheelchair for mobility. Resident #4 had functional limitation of range of motion on both sides of his upper extremities and one side of his lower extremities.A review of Resident #4's active physician orders for the month of March 2026 revealed the following medication orders:Quetiapine (Seroquel) 25mg (milligrams), give one tablet orally every 12 hours for Alzheimer's disease.Donepezil (Aricept)10 mg once daily at 8:00 AM for Alzheimer's disease.Metformin ER (extended release) 500mg, give once daily at 8:00 AM for DM.Propranolol ER 60mg, give once daily at 8:00 AM for hypertension.Citalopram 10 mg, give 0.5 (one-half tablet) 5mg once daily at 8:00 AM for depressive disorder.Review of Resident #4's Medication Administration Record (MAR) for March revealed on 3/11/26 Resident #4's morning medications were documented as administered at 8:27 AM by Medication Aide #1.Resident #47 was admitted to the facility on [DATE].A review of Resident #47's active physician orders for the month of March 2026 included the following medication orders: Donepezil 5 mg, give one orally one time a day at 8:00 AM related to Alzheimer's disease.Metoprolol Succinate ER 25mg, give one tablet orally one time a day for atrial fibrillation.Amlodipine 5mg daily for essential hypertension.Tamsulosin 0.4 mg for benign prostatic hyperplasia.MA #1 was interviewed on 06/25/2026 at 7:54 AM and revealed he recalled working with Resident #4 on 03/11/2026 and giving Resident #4 his scheduled morning medications on 03/11/2026 at approximately 8:30 AM in the common area. MA #1 indicated he returned to the medication cart and prepared Resident #47's medication and returned to the common area and without realizing it, administered Resident #47's medications to Resident #4. Approximately 30 minutes later, MA #1 stated he realized he had given Resident #4 medications that should have been administered to Resident #47. He stated he immediately informed Nurse #1 about the medication error. MA #1 stated Resident #4 appeared to be sleepy prior to EMS arrival.Review of nurse progress note dated 03/11/2026 at 2:26 PM written by Nurse #1 revealed Resident #4 received his scheduled medications on the morning of 03/11/2026 and his roommate's (Resident #47) scheduled medications. Resident #4 received metoprolol 25mg ER, tamsulosin 0.4mg, norvasc (amlodipine) 5mg, and aricept (donezepil) 5mg. Review of vital signs documented by the facility on 3/11/2026 at 10:32 AM revealed heartrate of 36 and BP of 90/60.An interview was conducted with Nurse #1 on 06/25/2026 at 8:39 AM and revealed the MA on duty (MA #1) came to her on 3/11/26 between 8:30 AM and 9:00 AM and reported he had accidentally given Resident #4 Resident #47's medication in error. Nurse #1 indicated when she first assessed Resident #4, she recalled obtaining and writing down his vital signs and remembered Resident #4's heartrate was in the 60's and his blood pressure (BP) was within normal limits. Nurse #1 could not recall Resident #4's blood pressure. Nurse #1 stated she knew the NP was in the facility and went to get her. Nurse #1 recalled when she and the NP arrived to assess Resident #4 his heartrate had begun dropping into the 40's bpm. The NP gave orders to send Resident #4 out to be evaluated at the hospital and EMS was called and arrived on-site 5 to 10 minutes later.Review of Resident 4's NP provider's note dated 03/11/2026 revealed Resident #4 was being seen per nursing request. The NP progress note revealed Resident #4 was given his medication, and in addition, Resident #47's medication on the morning of 03/11/2026. The provider's note also indicated upon assessment, Resident #4's heart rate was in the 40's range and dropped into the high 30's. Resident #4 was hypotensive with a blood pressure reading of 90/60. The decision was made to call 911 and Resident #4 was sent to the hospital for further management. NP interview 06/25/2026 at 10:28 AM revealed Resident #4 had a medication error on 03/11/2026. The NP indicated on 03/11/2026 Nurse #1 notified her of a medication error occurred when Resident #4 received all his scheduled morning medications and Resident #47's scheduled morning medications. Upon assessing Resident #4 at approximately 10:00 AM, he was symptomatic to include his heartrate being 30 to 40 bpm and he was lethargic but arousable. NP stated Resident #4 could have experienced a drop in heart rate because of the betablockers he was prescribed. When the NP was asked, were his symptoms of his heart rate dropping into the 30 to 40 bpm range a direct result of receiving another resident's medications (Resident #47) that were not prescribed to him, her answer was, Most likely, yes.Review of the EMS records dated 03/11/2026 indicated EMS was contacted at 10:34 AM regarding a possible medication error. The EMS record indicated they arrived at the facility at 10:52 AM and were at the bedside at 10:54 AM. Resident #4's vital signs were taken and revealed a heartrate of 43 bpm and blood pressure of 144/69. Per EMS report nursing staff (not named) stated Resident #4 had received an extra blood pressure pill but wasn't sure which one. A second staff member (not named) arrived and stated Resident #4 had received all his morning medications and another resident's morning medications which included propranolol 60mg and metoprolol succinate ER 25mg. Resident #4 was alert and transported via EMS and arrived at the hospital at 11:06 AM. An attempt to start an IV was unsuccessful due to Resident #4's movement.Review of the hospital emergency department (ED) provider note and History and Physical (H&P) dated 03/11/2026 noted Resident #4 was hypotensive and severely bradycardic with pulse rate in the 20's. The physician documented the principal problem was severe symptomatic bradycardia and hypotension secondary to an unintentional medication overdose with betablockers and amlodipine. ED triage vital signs included BP 123/68 and pulse 40 bpm. The resident received epinephrine drip and atropine for his low heart rate. Blood pressures improved and his heart rate was in the mid 40's. The plan was to continue the epinephrine drip and transfer the resident to the Critical Care Unit (CCU) for monitoring. The physician noted they would hold Resident #4's donepezil, propranolol and quetiapine given concerns for bradycardia and would monitor with telemetry. Donepezil, propranolol and quetiapine are all AV [NAME] blockers which slow electrical conduction through the atrioventricular (AV) node of the heart. The hospital Discharge summary dated [DATE] indicated Resident #4 was admitted to the hospital on [DATE]. The physician noted Resident #4 was a [AGE] year-old male with a history of sinus bradycardia, hypertension associated with type II DM, noninsulin-dependent DM, moderate Alzheimer's dementia, and failure to thrive who was admitted for symptomatic sinus bradycardia. He was admitted after he received his prescribed propranolol and metoprolol, amlodipine and tamsulosin resulting in severe bradycardia and hypotension. Active hospital problems included symptomatic bradycardia, complete heart block and sinus bradycardia (first noted 2/28/25). Initial management included epinephrine infusion and atropine with limited response which suggested a high degree heart block. Resident #4's hospital electrocardiogram ECG results showed progression from sinus bradycardia with a second-degree AV block to a complete heart block. On 3/13/26 Resident #4 was implanted with dual-chamber pacemaker. The resident's clinical status improved, and he was discharged back to the facility on 3/16/26.Pharmacist interview on 06/25/2026 at 4:46 PM revealed metoprolol 25mg ER would release slower throughout the day, but due to Resident#4 receiving his scheduled betablockers, and then getting his roommates (Resident #47) betablocker and alpha betablocker, this would be the cause of Resident #4's drop in heartrate and BP. She further stated the combination including other medications which can lower BP, including tamsulosin, would have been the cause of Resident #4's change in condition.Interview with the Medical Director 06/25/2026 at 11:35 AM revealed she recalled being informed by the NP about Resident #4 receiving another resident's medications in addition to his scheduled medications. The Medical Director indicated metoprolol succinate 25mg was an extended-release meaning and it entered the resident's body system slowly and not acutely (immediate releasing). The Medical Director indicated the medication error could have caused Resident #4's heartrate to decrease into the 30's to 40's and stated any blood pressure pill can cause a decreased heart rate and BP. She stated due to Resident #4's age and comorbidities, his symptoms of low BP and low heartrate could have happened at any time and did not feel this medication error contributed to Resident #4's symptoms of low blood pressure and low heartrate. Interview with the Administrator on 6/25/2026 at 4:30 PM, revealed she became aware of the medication error involving Resident #4 after the Medication Aide #1 informed Nurse #1. The root cause of this incident was a medication administration error related to Medication Aide #1's failure to properly verify Resident #4 identity according to established protocols. The Administrator was notified of the Immediate Jeopardy (IJ) on 06/25/2026 at 5:45pm. The facility completed a Plan of Correction (POC) to include reeducation of medication administration, identifying the correct resident, facility medication policies, observation individual med pass of all staff who pass medications to ensure proper protocol was followed when identifying a resident. The Administrator provided the following corrective action plan with a compliance date of 3/19/2026. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On March 11, 2026, at approximately 8:20 AM, during a routine medication pass, Medication Aide #1 administered Resident #4 his prescribed medications which included Quetiapine 25 mg, Donepezil 10 mg, Metformin ER 500 mg, Propranolol ER 60 mg, Citalopram 10 mg. Medication Aide #1 returned to the medication cart and prepared Resident #47's medications which included Donepezil 5 mg, Tamsulosin 0.4 mg, Eliquis 5 mg, Memantine HCL 5 mg, Metoprolol Succinate ER 25 mg, and Amlodipine 5 mg and administered them to Resident #4 in error. Medication Aide #1 realized the error and reported this to the nurse approximately 15 to 30 minutes upon discovery of the error and the Director of Nursing (DON) and the Nurse Practitioner were notified. Resident #4 was promptly assessed by the DON and a nurse, which included vital signs revealing Resident #4's pulse to be 36 (bradycardic) and O2 saturation 94%. Resident #4 was found to be lethargic and in no acute distress, sitting up in his wheelchair. Which prompted floor staff to notify the Nurse Practitioner to provide a more comprehensive assessment immediately. The Nurse Practitioner (NP) assessed the resident and found him to be bradycardic and hypotensive. The NP determined the resident needed to be sent to the hospital ED for an evaluation. Resident #4 was transported to the hospital at 10:00 AM on March 11, 2026. Hospital diagnoses included severe bradycardia, sinus bradycardia, and hypotension. Hospital ECGs demonstrated progression from sinus bradycardia with second-degree AV (Mobitz 1) block to marked sinus with first-degree AV block, and ultimately to complete heart block. Review of the hospital records indicated Resident #4 had a pacemaker placed during the hospitalization on March 13, 2026, and did not receive any new medication orders. Resident #4 returned to facility on March 16, 2026, where he resumed and continued hospice services at prior baseline. The root cause of this incident was a medication administration error related to failure to properly verify resident identity according to established protocols. On March 11th, 2026 immediately after identifying medication error occurred Medication Aide #1 was removed from medication administration duties pending investigation and retraining. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practices. There were no medication discrepancies identified for trend review, and no medication errors had been noted within the last six months. Because a medication administration error has the potential to affect all residents, the facility conducted a review focused on the performance of the nursing staff and Medication Aide through medication pass evaluations where staff demonstrate the 7 rights of medication administration. Between March 13, 2026 and March 18, 2026 the Assistant Director of Nursing and designee completed medication administration evaluations on all licensed nurses and medication aides ensuring that all licensed nurses and medication aides demonstrated competency in applying the 7 Rights during medication administration. All Licensed Nurses and Medication Aides who were responsible for medication administration including Medication Aide #1 were evaluated by using the facility's Medication Pass Evaluation Form, which includes four required areas of competency. The four competency areas included: (1) proper medication preparation and resident identification according to the Rights of Medication Administration prior to medication administration; (2) adherence to the Rights of Medication Administration, including the right resident, medication, dose, route, and time; (3) compliance with medication-specific instructions and documentation requirements, including medication parameters, administration instructions, medication crushing procedures when applicable, documentation immediately following medication administration, and controlled substance documentation; and (4) appropriate communication and timely reporting of any medication errors or concerns to the supervisor were included in medication pass evaluation observation competency to ensure medication errors were recognized and reported timely. These competencies of resources listed above are available in the agency education binder which is required to review before any worked shifts. The medication pass evaluations included direct observation of an actual medication pass to ensure medications were administered safely and in accordance with physician orders and facility policy. During this evaluation process, no concerns were identified with staff adherence to resident identification procedures, medication specific parameters, or crushing requirements. Staff demonstrated appropriate knowledge of reporting expectations. All licensed nurses and medication aides hired after March 18, 2026 received this same education and competency evaluation during orientation, provided by the Director of Nursing or designee, to ensure consistent understanding of medication administration expectations from the beginning of employment and ongoing compliance. Overall responsibility for ensuring completion of education, competency validation, and ongoing compliance remains with the Director of Nursing and the Assistant Director of Nursing. On March 11, 2026 and March 12, 2026 the Director of Nursing (DON) completed Medication Administration Record (MAR) audits for all current residents to ensure all resident admission, discharges, and medication order changes via provider orders were accurate. The MAR audits included review of the census sheet for March 11, 2026 and March 12, 2026, verification of any missed medications or medications not administered, and a full audit comparing all medications on the MAR to the physician order summary to ensure accuracy and consistency of orders and documentation. The DON determined there were no medication administration issues identified. On March 11, 2026, after the facility became aware of the incident all current residents were placed under observation for any changes in health status by Director of Nursing or Designee, to identify any deviations from baseline condition including neurologically via resident interviews or if any unintended harm was done from an adverse event relating to a medication error. Residents were observed for any adverse signs or symptoms related to medication administration, and no concerns were identified. No residents required further medical intervention as a result of these observations. 3. Address what measures will be put into place, or systemic changes made to ensure that the deficient practice will not recur. To ensure that this deficient practice does not recur, the facility has implemented several systemic changes focused on strengthening staff competency, reinforcing adherence to the 7 Rights of Medication Administration, and establishing ongoing quality monitoring audits. By March 18, 2026, all licensed nurses and medication aides were educated by the DON in person and via the phone on resident rights related to medication administration, with specific emphasis on the 7 Rights of Medication Administration, including the right resident, right medication, right dose, right route, right time, and right documentation. The staff members educated via phone were reeducated in person by the Assistant DON during the medication pass evaluation observation. This education reinforced the importance of accurate resident identification prior to medication administration. Staff were educated to utilize the resident photograph displayed in the electronic Medication Administration Record (eMAR) to properly identify the correct resident before administering medications. Education also reinforced that resident identification must be verified prior to each medication administration and that staff were expected to follow facility policy regarding resident identification at all times. Education was provided in person to all licensed nurses and medication aides by the Director of Nursing starting on March 11, 2026 and concluding on March 18th, 2026. The 7 rights of medication administration were added to the new hire orientation training via in person education and demonstrated during medication pass evaluation observation. Since the incident, the facility has had one new hire, who received the required education during orientation and was observed completing medication administration competency prior to working independently on the floor. The 7 rights of medication administration was added to the agency staff onboarding binder. Agency nurses are required to review the onboarding binder upon entering the facility for each shift, which includes facility policies and procedures, prior to providing resident care. 4. How will the facility monitor its corrective action to ensure the deficient practice will not recur? A Quality Monitoring Audit was initiated on March 11, 2026 to evaluate compliance with the facility's medication administration policy, including adherence to the 7 rights and resident identification procedure by Director of Nursing and/or designee. The Director of Nursing or Assistant Director of Nursing conducted random audits of medication administration passes with 2 Licensed Nurses or Medication Aides weekly for 12 weeks, to ensure adherence of the 7 rights of medication administration, which included right medication, right resident, right dose, right time, right route, right reason, and right documentation. Quality Monitoring Auditing was conducted on both 1st shift (7:00 a.m. to 7:00 p.m.) and 2nd shift (7:00 p.m. to 7:00 a.m.) to ensure ongoing compliance with medication administration practices and identified concerns were addressed through immediate feedback and reeducation as indicated. The results of the quality monitoring were reported by the Director of Nursing or Designee to the Quality Assurance Performance Improvement Committee meeting for 3 months, no negative findings noted. The Quality Assurance Performance Improvement Committee members consist of but not limited to the Care Service Administrator, Director of Nursing, Assistance Director of Nursing, Social Worker, Activities Director, Health Care Liaison, Medical Director, Maintenance Director, Minimum Data Assessments Nurse, and at least one direct care staff member. Alleged date of immediate jeopardy removal and compliance date: 3/19/26.The validation of the corrective action plan was completed on 07/01/2026.The facility completed a six month review of medication records to identify any trends or patterns; no discrepancies, trends, or patterns were identified. Between March 13-16, 2026, the Assistant Director of Nursing conducted comprehensive medication pass evaluations on all staff nurses and Medication Aides. Agency staff received Medication Administration education before each shift and signed verification of training completion. This was confirmed by a review of in-service sign in sheets. Staff interviews further confirmed that nurses, medication aides, and agency staff had completed the required education and were able to verbalize the 7 rights of medication administration, utilizing the resident photograph displayed in the electronic Medication Administration Record (eMAR) to properly identify the correct resident, and the importance of reporting any medication error. This was further confirmed by a review of in-service sign in sheets. The facility also provided documentation demonstrating that newly hired staff and agency personnel assigned to Medication Administration duties had received current training.A Medication Administration Observation was completed during the validation with no medication errors noted.The facility submitted documentation confirming completion of weekly direct observation medication pass audits for two staff members per week over a 12 week period, in accordance with corrective action plan. The facility also provided documentation and interviews related to the Quality Assurance and Performance Improvement (QAPI) Committee meetings.The immediate jeopardy removal and compliance date of 3/19/26 was validated.

Based on observations and staff interviews, the facility failed to maintain the dumpster area free of trash and debris for 1 of 1 dumpster area observed for garbage storage and ensure dumpster doors remained closed for 2 of 2 dumpsters. These practices had the potential to attract pests and rodents.An observation of the dumpster area located outside of the kitchen near the facility was conducted on 6/24/2026 at 3:22PM with the Director of Dining Services. The observation revealed multiple pieces of trash and debris including cardboard pieces, multiple used plastic gloves, and a bag of trash pushed in the back corner with a corner of the bag under one of the dumpsters, which was visible by walking around the two dumpsters that were side by side. Both dumpsters' slide doors were not fully closed.An interview with the Director of Dining Services on 6/24/2026 at 3:25PM, revealed that he thought the trash was stuck under the dumpster and they called the dumpster company about a week ago to see when the dumpster company could come out and lift it up so the facility could clean under it. The Director of Dining Services revealed that the dumpster company came 3 times per week to empty the dumpsters. The Director of Dining Services explained the trash on the ground was not acceptable and it could attract rodents. He stated the Director of Facility Services would know more.On 6/24/2026 at 4:00PM the Director of Facility Services presented an email, dated 6/24/2026, from the dumpster company that stated the dumpster company would come 7/3/2026 to install a trash compactor and they could clean the area at that time.An interview on 6/25/2026 at 9:27AM with the Director of Dining Services, the Director of Facility Services, and the Administrator present confirmed that the dumpster company came 3 times per week to empty the dumpster. The Director of Facility Services explained the dumpster company came at 4:00AM. He stated no one was at the facility at that time except the security guard and he could not do it.An observation of the dumpster area on 6/25/2026 at 9:29AM revealed a new trash bag in addition to the other trash seen on 6/24/2026 was now present along with a bag halfway out of the dumpster, with the dumpsters' sliding doors not fully closed.An interview with Dietary Aide #1 on 6/25/2026 at 9:31AM confirmed that the trash bag on the ground should not have been there. She did not know how the trash got there. The Dietary Aide #1 threw a trash bag directly into the dumpster and then closed the dumpster's sliding door. An observation of the dumpster area with the Director of Dining Services on 6/25/2026 at 9:39AM, confirmed that he saw the new trash on the ground and he picked it up and placed the trash into the dumpster. He then closed the dumpsters' sliding doors.An interview with the Director of Dining Services on 6/25/2026 at 9:40AM confirmed that the sliding doors on the dumpster should have been closed and there should have been no trash on the ground. An observation of the dumpster area on 6/25/2026 at 5:30PM revealed a trash bag on the ground below an open dumpster's sliding door. A phone interview with the dumpster service company on 6/26/2026 at 8:25AM confirmed the dumpster company sends a truck out to the facility 3 times per week during the early morning and usually no later than 7:00AM to empty the dumpster area. The dumpster company also confirmed the company would allow the facility to schedule services in addition to the regular scheduled times.

Based on observations, record review, and interviews with the Pharmacist from the dispensing pharmacy and facility staff, the facility failed to: 1) discard expired medications (medication room and upper 500 hall medication cart); 2) label medications when opened and dispose of loose nebulization solutions in the bottom drawer (low 500 hall medication cart); and 3) secure prescription medications in a locked compartment (low 500 hall medication cart). These failures occurred for 1 of 1 medication room and 2 of 2 medication carts reviewed for proper storage and labeling of medications. 1a) An observation of the refrigerator in the medication room accompanied by Nurse #3 conducted on 6/25/2026 at 11:38 AM revealed the following expired medications stored in the medication storage refrigerator with other non-expired medications: Flucelvax (flu immunizations) which expired 6/10/2026 and 6 daptomycin (a strong antibiotic used for certain serious bacterial infections) intravenous bags which expired on 6/13/2026, 6/20/2026, 6/21/2026, 6/22/2026, 6/23/2026, and 6/24/2026.Nurse #3 confirmed expired medications should not be in the refrigerator with the non-expired medications on 6/25/2026 at 11:40 AM. She confirmed that the Director of Nursing (DON) would know how the expired medications were discarded.1b) An observation of the medication cart on the upper 500 hall was conducted on 6/25/2026 at 12:02 PM accompanied by Nurse #1. The observation revealed an Advair prescription inhaler (used for chronic lung disease) was labeled with an expiration date of 6/22/2026 and was stored in the medication cart with the other inhalers.An interview with Nurse #1 on 6/25/2026 at 12:05 PM confirmed that an expired medication should not be in the upper 500 hall medication cart. Nurse #1 stated that it needed to be discarded and that it would be stored in the medication room until the pharmacy came next and collected it.An interview with the Director of Nursing (DON) on 6/25/2026 at 12:20 PM confirmed that when staff came across expired medication it should be stored in the medication room separate from the other medications. She pointed to a bag on the floor of the expired medications awaiting return to the pharmacy. The DON then pulled all of the daptomycin and flu shots from the refrigerator and she placed them in the bag on the floor of expired medications. The DON confirmed keeping the expired medications with the non-expired medications could result in a resident receiving an expired product.An interview with the facility Administrator on 6/25/2026 at 3:00 PM revealed she expected all staff to follow the facility procedure on medication storage and expired medications should be discarded.2) Review of the fluticasone furoate/vilanterol's (a medication used to control and prevent breathing difficulties) manufacturer guidelines, last updated in June 2024, for storage stated once open the inhaler must be discarded after 42 days.The manufacturer guidelines for Stiolto (a daily inhaler to help control breathing difficulties), last revised in June 2025, stated to discard 3 months after inserting the cartridge into inhaler.The levalbuterol's (a medication used to treat wheezing, shortness of breath, and coughing) manufacturer guidelines, last updated in October 2023, for storage stated that once the pouch was open it should be used within 2 weeks. Review of the manufacturer guidelines, last revised in October 2023, for ipratropium bromide (a medication used to control and prevent breathing difficulties) stated the nebulizing vials should be protected from light and stored in the foil pouch.An observation accompanied by Nurse #3 was conducted on the medication cart near the lower 500 hall on 6/25/2026 at 11:49 AM. The observation revealed the following medications were not properly labeled with the open date: fluticasone furoate/vilanterol inhaler was opened up with 20 doses left on the counter, Stiolto was opened with 4 doses removed, and a pouch of levalbuterol nebulizing solution was opened with 16 of 25 vials remaining. The observation also revealed 4 loose nebulizing solution vials of ipratropium bromide were in the bottom drawer not stored in their foil package.An interview on 6/25/2026 at 11:51 AM with Nurse #3 confirmed that medications that were opened from a pouch or inhaler box that should be labeled with the opened date. Nurse #3 reported that the loose vials should have been discarded and they should not have been stored like that. Nurse #3 retrieved the vials to discard themAn interview with the Director of Nursing (DON) on 6/25/2026 at 12:20 PM confirmed that when staff opened any medications from a pouch or inhaler the staff should label it with the opened date and medications should not be stored in the bottom of the drawer loose and not in their original foil package. The DON also stated that the Pharmacist from the dispensing pharmacy would visit the facility monthly and perform medication cart audits.An interview with the facility Administrator on 6/25/2026 at 3:00 PM revealed she expected all staff to follow the facility procedure on medication labeling and storage.3) An observation of the medication cart near the lower 500 hall on 6/25/2026 at 10:45 AM revealed the cart had been left unattended and 2 prescription blister packs of medications were not secure and laid on top of the medication cart. There were no staff or residents present in sight of the medication cart.A second observation of the medication cart near the lower 500 hall was conducted on 6/25/2026 at 10:50 AM revealed the medications were still left unattended on top of the medication cart and not secure. There were no staff or residents present or in sight of the medication cart.An interview with Nurse #3 on 6/25/2026 at 10:52 AM revealed that she pulled the medications out of the lower 500 hall medication cart as they were not filed in the correct drawer. Nurse #3 stated she meant to put them back after going to a resident's room to administer medications, but she was pulled away by a family member needing help finding the Social Worker's office. Nurse #3 led the family member to the Social Worker's office which was located down the hall and around two corners. Nurse #3 stated she was pulled in many directions and stated unattended medication carts should have all medications locked up and the computer screen closed to prevent any person from grabbing the medication and taking it.An observation of the medications left on top of the lower 500 hall medication cart unattended on 6/25/2026 at 10:54 AM revealed the medications were a blister card of 14 tablets of amlodipine 2.5mg (a medication used to lower blood pressure) and another blister card of 4 capsules of rifampin 300mg (a medication used to kill certain types of bacteria and can cause clinically significant drug interactions by reducing the effectiveness of many medications).An interview with the Director of Nursing (DON) on 6/25/2026 at 10:55 AM confirmed the facility policy of storing medications was to ensure medications were stored inside the medication cart and locked when the cart was left unattended. The DON stated dementia residents could grab them and take them. The DON also confirmed that the facility does training for medication storage at orientation.The Pharmacist from the dispensing pharmacy confirmed on 06/25/2026 at 11:10 AM she had serviced the facility for 10 years. The Pharmacist expected medications to be secured and locked inside an unattended medication cart. The Pharmacist expected that only the nurse would have the key if the cart was left unattended. She stated the risk of leaving medications unsecure was that anyone can grab them and if ingested could experience adverse side effects. The Pharmacist from the dispensing pharmacy stated that if someone ingested amlodipine there may have been a risk for hypotension and if someone ingested rifampin one dose may not cause harm but if they took them all that may have been a different story.An interview with the facility Administrator on 06/25/2026 at 11:17 AM revealed she expected all staff to follow the facility procedure on medication storage and that medications should not have been left unsecure if a medication cart was unattended.

Based on observations and staff interviews, the facility failed to ensure dietary staff with facial hair wore beard covers for 2 of 6 male staff members observed for food preparation and service (Director of Dining Services and the Sous Chef). This practice had the potential to affect food served to residents.An observation of the kitchen was conducted on 6/24/2026 at 11:00AM - 11:40AM of the Director of Dining Services. During this time the Director of Dining Services presented with a full dark beard and mustache, approximately 1/2 to 1 inch in length, preparing and serving food without a beard cover. The Director of Dining Services was observed performing the following tasks in the kitchen: on 6/24/2026 at 11:15AM placed plastic wrap over individual peach bowls off the steam table, on 6/24/2026 at 11:20AM grabbed pork chop tray assisting dietary aide with removing the pork chops from the tray on steam table, placed tongs into pork chops on the steam table on steam table, on 6/24/2026 at 11:25AM placed lid over sweet potatoes on the steam table, handled salads from refrigerator off the steam table, and on 6/24/2026 at 11:30AM performed the temperature checks of all hot food on the steam table.An observation of the kitchen was conducted on 6/24/2026 at 11:00AM - 11:40AM of the Sous Chef. During this time the Sous Chef presented with a chin beard (goatee-style facial hair), approximately 2 to 3 inches in length, preparing food without a beard cover. The Sous Chef was observed performing the following tasks: on 6/24/2026 at 11:21AM moved pork chops from storage bags onto cooking tray, on 6/24/2026 at 11:23AM entered steam table area to grab seasoning and then seasoned pork chops, and on 6/24/2026 at 11:25AM placed pork chop tray into oven.An interview with the Director of Dining Services on 6/24/2026 at 11:35AM, revealed that his expectations about beard covers for males were that per his health regulations if longer than an individual's eye lashes then a beard cover must be worn. The Director of Dining Services said he does not think he needed to wear a beard cover, but the Sous Chef should have one on.The Sous Chef confirmed in an interview on 6/25/2026 at 7:49AM that the Director of Dining Services told him to wear a beard cover. He thought the policy was 2 to 3 inches required a beard cover. The Sous Chef stated he had just forgotten the other day.During an interview on 6/25/2026 at 8:20AM with the facility Administrator, she indicated that she expected staff to follow the regulations for beard covers.

Based on record review and staff, Nurse Practitioner (NP), and resident interviews, the facility failed to ensure advanced directives (code status) was accurate throughout the medical record for 1 of 1 resident reviewed for advance directives (Resident #9).Resident #9 was admitted into the facility on 9/19/2025.An encounter note dated 3/4/2026 for Resident #9 from NP #2 stated Resident #9 had a Do Not Resuscitate (DNR) code status.A quarterly encounter note dated 3/10/2026 for Resident #9 from the Social Worker stated Resident #9's code status was DNR.Review of 2 advance directive orders for Resident #9 both dated 3/25/2026 by NP #1 showed cancellation of full code status and initiated a DNR status. An encounter note dated 4/10/2026 for Resident #9 from NP #1 stated Resident #9 had a full code status.Resident #9's Medical Order Scope of Treatment (MOST) dated 5/7/2026 and signed by NP #2 had a DNR status.An encounter note dated 6/15/2026 for Resident #9 from NP #1 stated Resident #9 had a full code status.Review of the quarterly Minimum Data Set (MDS) assessment completed on 6/18/2026 revealed that Resident #9 was cognitively intact. Review of the comprehensive care plan revised on 6/18/2026 revealed that Resident #9 had a full code status.Encounter notes for Resident #9 from NP #2 stated Resident #9 had a full code status on the following dates: 3/9/2026 and 5/11/2026. A quarterly encounter note dated 6/22/2026 for Resident #9 from the Social Worker stated Resident #9 was DNR.An interview with Resident #9 on 6/24/2026 at 9:05AM revealed she wanted DNR.An interview with Nurse #2 on 6/24/2026 at 7:41AM confirmed she knew where to find a resident's advance directive in the facility's medical electronic record system and said the staff would also look in their advance directive notebook at the nursing station. She confirmed Resident #9 was currently DNR.An interview with the DON on 6/24/2026 at 7:42AM confirmed she expected that the care plan would match the most recent MOST sheet and the resident representative or resident's wishes. She confirmed if the advance directive was changed, she would update the order and care plan. The DON was unsure why the care plan was not updated to match the advance directive for Resident #9, she stated it probably slipped through the cracks.An interview with the facility Social Worker on 6/24/2026 at 2:43PM confirmed she would help the facility update the MOST. She confirmed her encounter notes for Resident #9 that stated Resident #9 was DNR was accurate. She expected that the encounter notes and care plan should match the MOST, but she was not responsible for updating the care plan. An interview with NP #1 on 6/24/2026 at 2:29PM confirmed the process of when a resident changed their advance directive from full code status to DNR was that the nursing staff would notify her and if she was told then she would notify the Nurse and Social Worker. The facility would need to update the MOST for any change. NP #1 stated she was familiar with Resident #9 and that Resident #9 was currently DNR, and she then confirmed this by looking in the electronic medical record. She stated she would expect her encounter notes and the care plan to match with the electronic medical record information by the resident's picture and what was on the MOST. An interview with NP #2 on 6/24/26 at 2:53PM, confirmed she had an encounter note completed on 5/11/2026 which was after her 5/7/2026 review of the MOST. She stated that the resident representative or resident would have the conversation about the resident's advance directive with the facility. Then the Nurse and Social Worker worked together to carry through with the MOST form. If the nurse was notified by the Resident Representative or resident that a change was wanted, then the nurse would leave a note for the provider to update it, and the provider would confirm with the Resident Representative or resident before updating it. If a DNR status was removed, the paper would have been removed from the binder at the nursing station and if changed from full code to DNR then a new MOST was created. She expected the encounter note and the care plan to match what was on the most recent order in the resident's medical records and on the MOST.During an interview on 6/25/2026 at 8:20AM, the facility Administrator confirmed that the care plan should match the resident's advance directive and expects that the care plan should have been updated if changes arose.

Based on record review and staff interviews, the facility failed to meet professional standards of care when nursing staff administered medications prescribed for Resident #47 to Resident #4 for 1 of 5 residents reviewed for significant medication errors (Resident #4).Findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, Type II diabetes mellitus (DM), depression, hypertension, sinus bradycardia (2/28/25), psychotic disorder with hallucinations due to known physiological condition.A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired.Medication Aide (MA) #1 was interviewed on 06/25/2026 at 7:54 AM and revealed he recalled working with Resident #4 on 03/11/2026 and giving Resident #4 his scheduled morning medications on 03/11/2026 at approximately 8:30 AM in the common area. MA #1 indicated he returned to the medication cart and prepared Resident #47's medication and returned to the common area and without realizing it, administered Resident #47's medications to Resident #4. Approximately 30 minutes later, MA #1 stated he realized he had given Resident #4 medications that should have been administered to Resident #47. He stated he immediately informed Nurse #1 about the medication error. Review of Resident #4's Medication Administration Record (MAR) for March revealed on 3/11/26 Resident #4's morning medications were documented as administered at 8:27 AM by Medication Aide #1.Resident #47 was admitted to the facility on [DATE].A review of Resident #47's active physician orders for the month of March 2026 included the following medication orders:Eliquis 5 mg (anticoagulant medication) twice a day for atrial fibrillation.Memantine 5 mg -two tablets (10 mg total) twice a day related to unspecified dementia without behavioral disturbance, mood disturbance, and anxiety. Omeprazole 20mg -once daily for gastroesophageal reflux disease.Review of nurse progress note dated 03/11/2026 at 2:26 PM written by Nurse #1 revealed Resident #4 received his scheduled medications on the morning of 03/11/2026 and his roommate's (Resident #47) scheduled medications. Resident #4 received eliquis 5mg and omeprazole 20mg.An interview was conducted with Nurse #1 on 06/25/2026 at 8:39 AM and revealed the MA on duty (MA #1) came to her on 3/11/26 between 8:30 AM and 9:00 AM and reported he had accidentally given Resident #4 Resident #47's medication in error. Nurse #1 indicated when she first assessed Resident #4, she recalled obtaining and writing down his vital signs and remembered Resident #4's heartrate was in the 60's and his blood pressure (BP) was within normal limits. Interview with the Director of Nursing (DON) on 06/25/2026 at 3:45 PM revealed identity verification prior to administering medication was always the expectation of the facility's nurses and medication aides. The DON stated Medication Aide #1 has never made a medication error while working at the facility and she felt it was human error.Interview with the Administrator on 6/25/2026 at 4:30 PM, revealed she became aware of the medication error involving Resident #4 after the Medication Aide #1 informed Nurse #1. The root cause of this incident was a medication administration error related to Medication Aide #1's failure to properly verify Resident #4 identity according to established protocols. The Administrator provided the following corrective action plan with a compliance date of 3/19/2026. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On March 11, 2026, at approximately 8:20 AM, during a routine medication pass, Medication Aide #1 administered Resident #4 his prescribed medications which included Quetiapine 25 mg, Donepezil 10 mg, Metformin ER 500 mg, Propranolol ER 60 mg, Citalopram 10 mg. Medication Aide #1 returned to the medication cart and prepared Resident #47's medications which included Donepezil 5 mg, Tamsulosin 0.4 mg, Omeprazole 20 mg, Eliquis 5 mg, Memantine HCL 5 mg, Metoprolol Succinate ER 25 mg, and Amlodipine 5 mg and administered them to Resident #4 in error. Medication Aide #1 realized the error and reported this to the nurse approximately 15 to 30 minutes upon discovery of the error and the Director of Nursing (DON) and the Nurse Practitioner were notified. Resident #4 was promptly assessed by the DON and a nurse, which included vital signs revealing Resident #4's pulse to be 36 (bradycardic) and O2 saturation 94%. Resident #4 was found to be lethargic and in no acute distress, sitting up in his wheelchair. Which prompted floor staff to notify the Nurse Practitioner to provide a more comprehensive assessment immediately. The Nurse Practitioner (NP) assessed the resident and found him to be bradycardic and hypotensive. The NP determined the resident needed to be sent to the hospital ED for an evaluation. Resident #4 was transported to the hospital at 10:00 AM on March 11, 2026. Hospital diagnoses included severe bradycardia, sinus bradycardia, and hypotension. Hospital ECGs demonstrated progression from sinus bradycardia with second-degree AV (Mobitz 1) block to marked sinus with first-degree AV block, and ultimately to complete heart block. Review of the hospital records indicated Resident #4 had a pacemaker placed during the hospitalization on March 13, 2026, and did not receive any new medication orders. Resident #4 returned to facility on March 16, 2026, where he resumed and continued hospice services at prior baseline. The root cause of this incident was a medication administration error related to failure to properly verify resident identity according to established protocols. On March 11th, 2026 immediately after identifying medication error occurred Medication Aide #1 was removed from medication administration duties pending investigation and retraining. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practices. There were no medication discrepancies identified for trend review, and no medication errors had been noted within the last six months. Because a medication administration error has the potential to affect all residents, the facility conducted a review focused on the performance of the nursing staff and Medication Aide through medication pass evaluations where staff demonstrate the 7 rights of medication administration. Between March 13, 2026 and March 18, 2026 the Assistant Director of Nursing and designee completed medication administration evaluations on all licensed nurses and medication aides ensuring that all licensed nurses and medication aides demonstrated competency in applying the 7 Rights during medication administration. All Licensed Nurses and Medication Aides who were responsible for medication administration including Medication Aide #1 were evaluated by using the facility's Medication Pass Evaluation Form, which includes four required areas of competency. The four competency areas included: (1) proper medication preparation and resident identification according to the Rights of Medication Administration prior to medication administration; (2) adherence to the Rights of Medication Administration, including the right resident, medication, dose, route, and time; (3) compliance with medication-specific instructions and documentation requirements, including medication parameters, administration instructions, medication crushing procedures when applicable, documentation immediately following medication administration, and controlled substance documentation; and (4) appropriate communication and timely reporting of any medication errors or concerns to the supervisor were included in medication pass evaluation observation competency to ensure medication errors were recognized and reported timely. These competencies of resources listed above are available in the agency education binder which is required to review before any worked shifts. The medication pass evaluations included direct observation of an actual medication pass to ensure medications were administered safely and in accordance with physician orders and facility policy. During this evaluation process, no concerns were identified with staff adherence to resident identification procedures, medication specific parameters, or crushing requirements. Staff demonstrated appropriate knowledge of reporting expectations. All licensed nurses and medication aides hired after March 18, 2026 received this same education and competency evaluation during orientation, provided by the Director of Nursing or designee, to ensure consistent understanding of medication administration expectations from the beginning of employment and ongoing compliance. Overall responsibility for ensuring completion of education, competency validation, and ongoing compliance remains with the Director of Nursing and the Assistant Director of Nursing. On March 11, 2026 and March 12, 2026 the Director of Nursing (DON) completed Medication Administration Record (MAR) audits for all current residents to ensure all resident admission, discharges, and medication order changes via provider orders were accurate. The MAR audits included review of the census sheet for March 11, 2026 and March 12, 2026, verification of any missed medications or medications not administered, and a full audit comparing all medications on the MAR to the physician order summary to ensure accuracy and consistency of orders and documentation. The DON determined there were no medication administration issues identified. On March 11, 2026, after the facility became aware of the incident all current residents were placed under observation for any changes in health status by Director of Nursing or Designee, to identify any deviations from baseline condition including neurologically via resident interviews or if any unintended harm was done from an adverse event relating to a medication error. Residents were observed for any adverse signs or symptoms related to medication administration, and no concerns were identified. No residents required further medical intervention as a result of these observations. 3. Address what measures will be put into place, or systemic changes made to ensure that the deficient practice will not recur. To ensure that this deficient practice does not recur, the facility has implemented several systemic changes focused on strengthening staff competency, reinforcing adherence to the 7 Rights of Medication Administration, and establishing ongoing quality monitoring audits. By March 18, 2026, all licensed nurses and medication aides were educated by the DON in person and via the phone on resident rights related to medication administration, with specific emphasis on the 7 Rights of Medication Administration, including the right resident, right medication, right dose, right route, right time, and right documentation. The staff members educated via phone were reeducated in person by the Assistant DON during the medication pass evaluation observation. This education reinforced the importance of accurate resident identification prior to medication administration. Staff were educated to utilize the resident photograph displayed in the electronic Medication Administration Record (eMAR) to properly identify the correct resident before administering medications. Education also reinforced that resident identification must be verified prior to each medication administration and that staff were expected to follow facility policy regarding resident identification at all times. Education was provided in person to all licensed nurses and medication aides by the Director of Nursing starting on March 11, 2026 and concluding on March 18th, 2026. The 7 rights of medication administration were added to the new hire orientation training via in person education and demonstrated during medication pass evaluation observation. Since the incident, the facility has had one new hire, who received the required education during orientation and was observed completing medication administration competency prior to working independently on the floor. The 7 rights of medication administration was added to the agency staff onboarding binder. Agency nurses are required to review the onboarding binder upon entering the facility for each shift, which includes facility policies and procedures, prior to providing resident care. 4. How will the facility monitor its corrective action to ensure the deficient practice will not recur? A Quality Monitoring Audit was initiated on March 11, 2026 to evaluate compliance with the facility's medication administration policy, including adherence to the 7 rights and resident identification procedure by Director of Nursing and/or designee. The Director of Nursing or Assistant Director of Nursing conducted random audits of medication administration passes with 2 Licensed Nurses or Medication Aides weekly for 12 weeks, to ensure adherence of the 7 rights of medication administration, which included right medication, right resident, right dose, right time, right route, right reason, and right documentation. Quality Monitoring Auditing was conducted on both 1st shift (7:00 a.m. to 7:00 p.m.) and 2nd shift (7:00 p.m. to 7:00 a.m.) to ensure ongoing compliance with medication administration practices and identified concerns were addressed through immediate feedback and reeducation as indicated. The results of the quality monitoring were reported by the Director of Nursing or Designee to the Quality Assurance Performance Improvement Committee meeting for 3 months, no negative findings noted. The Quality Assurance Performance Improvement Committee members consist of but not limited to the Care Service Administrator, Director of Nursing, Assistance Director of Nursing, Social Worker, Activities Director, Health Care Liaison, Medical Director, Maintenance Director, Minimum Data Assessments Nurse, and at least one direct care staff member. Alleged date of compliance date: 3/19/26.The validation of the corrective action plan was completed on 07/01/2026.The facility completed a six month review of medication records to identify any trends or patterns; no discrepancies, trends, or patterns were identified. Between March 13-16, 2026, the Assistant Director of Nursing conducted comprehensive medication pass evaluations on all staff nurses and Medication Aides. Agency staff received Medication Administration education before each shift and signed verification of training completion. This was confirmed by a review of in-service sign in sheets. Staff interviews further confirmed that nurses, medication aides, and agency staff had completed the required education and were able to verbalize the 7 rights of medication administration, utilizing the resident photograph displayed in the electronic Medication Administration Record (eMAR) to properly identify the correct resident, and the importance of reporting any medication error. This was further confirmed by a review of in-service sign in sheets. The facility also provided documentation demonstrating that newly hired staff and agency personnel assigned to Medication Administration duties had received current training.A Medication Administration Observation was completed during the validation with no medication errors noted.The facility submitted documentation confirming completion of weekly direct observation medication pass audits for two staff members per week over a 12 week period, in accordance with corrective action plan. The facility also provided documentation and interviews related to the Quality Assurance and Performance Improvement (QAPI) Committee meetings.The compliance date of 3/19/26 was validated.

Based on observations, record reviews, and a Nurse Practitioner (NP) and staff interviews, the facility failed to adhere to the required personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP) for Resident #30, who had an indwelling urinary catheter (a soft tube inserted through the urinary opening into the bladder to drain urine) and unstageable pressure ulcer that required wound care, when Nurse Aide (NA) #4 was observed changing a fecal-soiled incontinent brief without wearing a gown. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (NA #4).A facility policy provided by the Director of Nursing (DON) titled 'Enhanced Barrier Precautions' last revised December 2024 indicated the facility would implement EBP utilized to prevent the spread of multi-drug-resistant organisms to residents. The policy stated EBP apply when a resident had an indwelling medical device. The policy would apply to all residents with any of the following indwelling medical devices: central lines, urinary catheters, feeding tubes, and tracheotomies. Examples of high-contact resident care activities listed in the policy included: dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing lines, prolonged high-contact with items in the resident's room, device care or use, and would care. EBP would remain in effect for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device.During an observation on 6/23/2026 at 3:02PM, an EBP sign was noted outside on Resident #30's door. The sign indicated that everyone must clean their hands before entering and after leaving room and all healthcare personnel must wear gloves and gowns for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care.NA #4 was observed entering Resident #30's room at 6/23/2026 at 3:10PM. NA #4 entered the room and donned gloves. NA #4 started to change Resident #30's brief. As she changed him, NA #5 entered Resident #30's room to see if NA #4 needed assistance. NA #5 donned gloves. NA #5 did not provide any direct contact to Resident #30.An interview with NA #5 at 6/23/2026 at 3:12PM confirmed that Resident #30 was the resident in the room requiring EBP.An interview with NA #4 at 6/23/2026 at 3:15PM confirmed that Resident #30 was the resident in the room requiring EBP. NA #4 stated it was because he had a catheter. She confirmed that EBP required healthcare personnel to don gloves and a gown when changing briefs. NA #4 stuttered and said, oh yea. She then confirmed she was supposed to wear a gown when changing him. She pointed out where the gowns were located which was right inside upon entering Resident #30's room. She confirmed she completed training on EBP at hire and annual training by signing completion. An interview on 6/24/2026 at 7:42AM with the Director of Nursing (DON), who was also the facility's Infection Preventionist, explained that all residents with an indwelling medical device would have EBP to prevent infections. She stated that all staff should follow the sign on the resident's door. She confirmed that Resident #30 had EBP because of his catheter and wound.An interview with NP #2 on 6/24/26 at 2:53PM, revealed that NP #2 expects staff to follow the sign on the door for EBP residents. She stated that changing a brief would require gloves and gown. During an interview on 6/25/2026 at 8:20AM with the facility Administrator, she indicated that she expects staff to follow the EBP sign.

Based on record review and staff interviews, the facility failed to obtain laboratory blood work as ordered for 2 of 5 residents reviewed for unnecessary medications. (Resident #4 and Resident #7) The findings included: 1.Resident #4 was admitted to the facility 1/3/24 with diagnoses type 2 diabetes mellitus, cognitive impairment, and lymphoma. Resident #4's admission Minimum Data Set (MDS) dated [DATE] revealed he was severely cognitively impaired and Resident #4 took insulin injections. An order for Resident #4 dated 1/3/2024 for a routine Complete Metabolic Panel (CMP), a Complete Blood Count (CBC) with differential, a Lipid Panel, and a Hemoglobin A1C was marked as completed by Nurse #5. Attempts to reach Nurse #5 were unsuccessful. Further review of Resident #4's medical record revealed there were no lab results for the 1/3/2024 order. During an interview with the Nurse Practitioner on 4/24/24 at 2:09 pm, she stated that when she orders blood work for a resident, she will either enter the order in the electronic chart herself or she will let the staff do it for her. She stated that she ordered blood work for this patient as a baseline upon admission due to his diagnosis of diabetes. She was unaware of the process used by the facility to communicate to the lab that a resident needed blood work drawn. She stated her expectation was she would order the lab work and the staff would ensure that it was done. She was unaware that Resident #4 had not had blood work completed by the lab. During and interview with the Director of Nursing (DON) on 4/25/24 at 10:47 am, she stated that with the current electronic chart system, the nurse will review any orders made by the nurse practitioner or doctor, submit all laboratory orders via paper requisition that the nurse fills out and it is placed in the external lab book at the nurse's station. She stated that the lab technician will come 5 or 6 times a week, draw the ordered lab work based on the requisitions in his/her notebook, and then send the results to the facility via fax when completed. The DON was unaware that two residents had not received their blood work as ordered and was unable to say why the order was marked completed. 2. Resident #7 was admitted to the facility on [DATE] with diagnoses dementia, type 2 diabetes mellitus, vitamin d deficiency and chronic kidney disease. Resident #7's quarterly MDS dated [DATE] revealed she was severely cognitively impaired. An order for Resident #7 dated 3/13/2024 for a routine Hemoglobin A1C, Vitamin D level, and a TSH (Thyroid stimulating hormone), was marked as completed by Nurse #5. Further record review showed there was no evidence of the lab being drawn. Attempts to reach Nurse #5 were unsuccessful. During an interview with the Nurse Practitioner on 4/24/24 at 2:09 pm, she stated that when she orders blood work for a resident, she will either enter the order in the electronic chart herself or she will let the staff do it for her. She stated that she ordered blood work for this patient as a 6 month monitor for her diabetes and vitamin d deficiency diagnoses. She was unaware of the process used by the facility to communicate to the lab that a resident needed blood work drawn. She stated her expectation was she would order the lab work and the staff would ensure that it was done. She was unaware that Resident #7 had not had blood work completed by the lab. During an interview with the Director of Nursing (DON) on 4/25/24 at 10:47 am, she stated that with the current electronic chart system, the nurse will review any orders made by the nurse practitioner or doctor, submit all laboratory orders via paper requisition that the nurse fills out and it is placed in the external lab book at the nurse's station. She stated that the lab technician will come 5 or 6 times a week, draw the ordered lab work based on the requisitions in his/her notebook, and then send the results to the facility via fax when completed. The DON was unaware that two residents had not received their blood work as ordered and was unable to say why the order was marked completed.

Based on a review of the facility arbitration agreement and administrative staff interviews, the facility failed to provide an arbitration agreement that 1) explicitly granted the resident or their representative the right to rescind the agreement within 30 days of signing it and 2) explicitly stated that neither the resident nor their representative were required to sign an agreement as a condition of admission to the facility. This agreement was provided in the admission packet and signed during the admission process for all residents residing in the facility. The findings included: A review of the facility arbitration agreement titled, Arbitration Agreement, was conducted. The Arbitration agreement stated to please read this agreement carefully, it waives certain rights that you may have, including your right to have a [NAME] trial on any claims that you may have against the community or its affiliates. The remainder of the arbitration agreement did not include verbiage that stated the resident or representative had the right to rescind the agreement in 30 days and that they were not required to sign the agreement as a condition of admission to the facility. An interview was conducted with the Administrator on 2/7/2022 at 10:01 a.m. He revealed that both he and the Executive Director reviewed the arbitration agreement, and it did not include the verbiage that the agreement was not required for admission or that the resident or representative had the right to rescind the agreement in 30 days. When the Administrator was asked if he had been aware of the regulatory requirements, he had stated he thought the admission agreement had covered the arbitration agreement as well.

Based on a review of the facility arbitration agreement and administrative staff interviews, the facility failed to provide an arbitration agreement that provided for 1) a selection of a neutral arbitrator agreed upon by both parties and 2) the selection of a venue that was convenient to both parties. This agreement was provided in the admission packet and signed during the admission process for all residents residing in the facility. The findings included: A review of the facility arbitration agreement titled, Arbitration Agreement, was conducted. The Arbitration agreement stated to please read this agreement carefully, it waives certain rights that you may have, including your right to have a [NAME] trial on any claims that you may have against the community or its affiliates. The agreement under section A) bullet point c) stated any dispute involving a resident's stay in the community shall be settled exclusively by binding arbitration conducted in accordance with the consumer rules of the American health law association. Any disputes concerning the scope, validity, or enforceability of this arbitration agreement shall be decided by an arbitrator, not a court. Any award of the arbitrator may be entered as a judgement in any court having jurisdiction. The remainder of the arbitration agreement did not include verbiage that stated a neutral arbitrator would be agreed upon by both parties (the facility representative and the resident or their representative) and did not state a venue would be selected that was convenient to both parties. An interview was conducted with the Administrator on 2/7/2022 at 10:01 a.m. He revealed that both he and the Executive Director reviewed the arbitration agreement, and it did not include the verbiage that an arbitrator would be selected by both parties and a venue convenient to both parties would be selected. When the Administrator was asked if he had been aware of the regulatory requirements, he had stated he thought the admission agreement had covered the arbitration agreement as well.

Based on record review and staff interviews the facility failed to report an injury of unknown origin to the state agency for 1 of 4 residents (Resident #10) reviewed for accident prevention. The findings included: Resident #10 was admitted on [DATE] with diagnoses of dementia, osteopenia, and major depressive disorder with psychotic symptoms. A review of Resident #10's significant change Minimum Data Set (MDS) dated [DATE] revealed she had severe cognitive impairment, required extensive assistance of two staff members with bed mobility, transfers, locomotion on the unit, toilet use, and dressing and total assistance of two staff members with personal hygiene. A review of the progress notes for Resident #10 documented on 10/20/2022 the Resident was discovered lying on her left side in the floor. The assessment reported no injuries and no pain. A review of the incident report for Resident #10 for the unwitnessed fall on 10/20/2022 documented the Resident was observed lying on her left side in the floor when a nurse walked past the room. A full body assessment was conducted, and vital signs preformed, with no apparent signs of injury observed. The Resident reported she was trying to transfer to the bed from the wheelchair and forgot to lock the brakes. The Resident was educated to call staff for assistance. A review of the nurse progress note dated 10/27/2022 documented the Resident was sent to the hospital due to a right-side lean, facial drooping, and weakness on the left lower extremity. She was unable to feed herself without staff assistance. A review of the Hospital emergency room records for 10/27/2022 revealed Resident #10 had a computed tomography (CT) scan of the head that was negative and a urine culture that was positive with an order for the same antibiotic previously ordered at the skilled nursing facility. No signs of an acute injury. She was not admitted and was transported back to the skilled nursing facility. A progress note dated 10/30/2022 documented the OT and the nursing assistant (NA) observed yellow bruising to the left thigh, left knee, and extended down the left leg. Range of motion (ROM) was preformed and no grimacing or pain was observed but the NA reported the Resident told her it hurt while doing ROM. A call was placed to the NP and an order to x ray the left leg was received. A progress note dated 10/31/2022 documented the x ray results were received and the Resident had a left hip comminuted fracture with moderate osteo arthritis at the left knee. On 11/1/2022 the Resident was transferred to the hospital for a surgical repair of the left hip. She was readmitted to the skilled nursing facility on 11/07/2022. An interview was conducted with the Administrator on 2/07/2023 at 2:18 p.m. and he revealed the facility had no reportable incidents for the last week of October and the month of November 2022. An interview was conducted with the DON on 2/7/2023 at 2:42 p.m. and she reviewed the incident report for the fall dated 10/20/2022 and all of the progress notes until the Resident's discharge on 11/1/2022. She stated an investigation into this injury did not occur because she had made the decision the bruising and fractured hip had occurred during the 10/20/2022 unwitnessed fall. When asked if multiple staff members had observed the Residents extremities from 10/20/2022 through 10/30/2022 she reported yes. When asked if they reported or documented observing bruising to the left lower extremity prior to 10/30/2022, she replied no. She added that when looking at the documentation, laid out all together, she felt an investigation should have been conducted for an injury of unknown origin. A follow up interview was conducted with the facility Administrator on 2/8/2023 at 11:53 a.m. and the Administrator stated an investigation was conducted for the bruising and injury, but the facility failed to thoroughly investigate all aspects of how the injury could have happened and did not report the incident to the state.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 8 residents (Resident #26) whose MDS assessments were reviewed. The findings included: Resident #26 was admitted to the facility on [DATE]. A review of the discharge return not anticipated MDS dated [DATE], indicated Resident #26 was discharged to an acute care hospital. A progress note dated 12/27/2022 documented Resident #26 was discharged to their home. An interview was conducted with the MDS coordinator on 2/10/2022 at 6:48 p.m. She revealed Resident #26 discharged home and she had entered the discharged to the hospital in error.

Based on observations, record reviews, and staff interview, the facility failed to ensure 1 of 4 sampled dependent residents (Resident #13) reviewed for activities of daily living (ADL), received nail care. Findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, atrial fibrillation, venous insufficiency, and abnormalities of gait and mobility. The care plan dated 9/16/22 revealed Resident #13 had a self-care deficit requiring extensive to total assistance with bathing and hygiene. Interventions included: staff to assist with ADLs (bathing, grooming, toileting, feeding, ambulating); and nursing assistants were to clean and manicure the resident's fingernails, as needed. The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #13 had moderately, impaired cognition requiring limited assistance with his hygiene and total assistance with his baths. The resident also had no behaviors of rejecting care. During an observation and interview on 2/8/23 at 10:13 a.m., Resident #13 was sitting in a motorized wheelchair in the front, living room area of the facility. The resident was dressed in day clothes but his fingernails on both hands were uneven/jagged and dirty with dark brown/black debris beneath the nails. When asked about receiving nail care, Resident #13 revealed the staff had never cleaned or trimmed his fingernails. The resident stated that he would prefer the staff trim and clean his fingernails, rather than attempting the task, himself. On 2/9/23 at 12:15 p.m., Resident #13 was observed in the dining room feeding himself lunch. The resident's nails were uneven/jagged and dirty with dark brown/black debris beneath nails. During an observation on 2/10/23 at 11:20 a.m., Resident #13 was sitting in his motorized wheelchair in the front, living room area of the facility. The resident's fingernails were jagged/uneven and dirty with dark brown/black debris beneath the nail tips. During an interview on 2/10/23 at 11:55 a.m., Nursing Assistant (NA#1) stated Resident #13 required assistance with ADL care (bathing, washing hands and face, grooming). She revealed that earlier that morning, she provided the resident with a bedbath which included washing his face and hands. NA#1 stated she did not clean or trim the resident's fingernails because she did not have the correct nail supplies and she did not know if the resident was diabetic. NA#1 stated that she was not a permanent employee at the facility but acknowledged she should have asked the nurse about the location of the supplies to clean Resident #13's fingernails. On 2/10/23 at 1:00 p.m., the Director of Nursing stated that nail cleaning and trimming supplies were available for use by nursing staff to clean and trim residents' nails. She confirmed NA#1 should have requested assistance in obtaining supplies needed to provide ADL care to Resident #13.

Based on observations and staff interviews, the facility failed to ensure the side doors and top lid of 1 of 1 trash dumpster remained closed when not in use, the area surrounding the dumpster remained free from garbage, refuse and foul odors. The facility also failed to ensure 1 of 1 cardboard dumpster was not used to maintain the facility's trash overflow. Findings included: During an observation from the parking lot of the facility on 8/23/21 at 9:00 a.m., large bags of trash were protruding from the opened top of a dumpster which was surrounded by a fence. On 8/23/21 at 11:00 a.m., during an observation of the fenced dumpster area with the Assistant Director of Dining Services (ADDS) there was a foul odor emitting from 1 of 1 trash dumpster and 1 of 1 cardboard dumpster within the fenced area. There were three large trash filled bags observed on the ground next to the trash dumpster and one bag of trash protruding from the opened side door of the cardboard dumpster. One of the two top lids of the dumpster was buckled at an upward angle with bags of trash protruding from the top of the dumpster. During an interview on 8/23/21 at 11:10 a.m., the ADDS indicated the waste management contractor was scheduled to empty the trash dumpster twice each week. He revealed the dumpster was used by the skilled nursing unit and the assisted living unit of the facility. The ADDS stated he reported the constant problem of the overflow of the trash and the cardboard dumpsters to administration and made suggestions, such as a trash compactor, larger dumpsters, or separate dumpsters for each unit of the facility; but had not received any response. On 8/24/21 at 8:10 a.m., there was an observation of an opened side door of the trash dumpster with trash bags inside. On 8/25/21 at 3:30 p.m., one of the side doors of the trash dumpster was observed open. There was trash bags inside the dumpster.

Based on record reviews and staff interviews, the facility failed to follow-up on the pharmacist's recommendation for the rationale for the use of [MEDICATION(S)] (antipsychotic medication) or to consider discontinuing its use for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. Findings included: Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance. Resident #8's clinical records and medication administration records revealed that on 4/29/21, the physician ordered [MEDICATION(S)] 12.5 mg (milligrams) which was administered every morning. On 4/30/21, the physician ordered [MEDICATION(S)] 25mg every 12 hours which was administered then discontinued on 5/1/21. On 5/1/21, the physician ordered [MEDICATION(S)] 25mg every evening at 5:00 p.m. which was administered. The pharmacist's recommendation to the physician/prescriber on 5/7/21 included the request for the diagnosis for the administration of [MEDICATION(S)] 12.5mg every day and 25mg in the evening or to consider discontinuing the medication if unnecessary. There was no documented response from the physician/prescriber. The clinical records revealed Resident #8 was hospitalized on [DATE] and was readmitted to the facility on [DATE] with orders for [MEDICATION(S)] 50mg every evening and 12.5mg every morning. The dosages were administered as ordered. The significant change minimum data set assessment dated [DATE] indicated Resident #8 was severely, cognitively impaired and was receiving an antipsychotic medication. Review of the undated pharmacist's recommendation to the physician/prescriber included the request for the diagnosis for the administration of [MEDICATION(S)] 12.5mg every day and [MEDICATION(S)] 50mg in the evening or to consider discontinuing the medication if unnecessary. There was also a statement indicating this recommendation was made in May 2021 but was not addressed by the physician/prescriber. This recent written recommendation was responded to and signed by the nurse practitioner on 7/1/21. The nurse practitioner's response to the [MEDICATION(S)] recommendation was will GDR (gradual dose reduction). The care plan updated 8/1/21 revealed Resident #8 was at risk for side effects from [CONDITION(S)] medications. Interventions included the pharmacist was to review the medications monthly with recommendations to the physician as needed. Review of the physician's orders and the August 2021 medication administration record revealed Resident continued to receive [MEDICATION(S)] 12.5mg every day through 8/24/21 and 50mg every evening through 8/23/21. There was no documentation of a physician's order for the reduction in the dosage of [MEDICATION(S)] for Resident #8. During an interview on 8/26/21 at 9:56 a.m., the Assistant Director of Nursing (ADON) revealed that part of the facility's communication procedure with the physician included the pharmacist would email any recommendations to the Director of Nursing who was responsible for ensuring the recommendations were placed in the Physician Communication book. The ADON stated she was unsure if the physician or the nurse practitioner reviewed the pharmacist's recommendation of 5/7/21 for a [MEDICATION(S)] dose reduction. After review of facility records, the ADON stated there was no GDR of [MEDICATION(S)] for Resident #8 in July 2021 or [DATE] because the nurse practitioner did not write the order. She stated there was no documentation indicating an order was given (written or verbally) for a GDR of [MEDICATION(S)] for Resident #8. During an interview on 8/26/21 at 2:51 p.m., the Nurse Practitioner recalled visiting Resident #8 on 7/1/21 but was unable to recall why she did not document about the [MEDICATION(S)] or write the order for the GDR of [MEDICATION(S)] or if she verbally instructed the nurse to write the order. When asked about the no response and no signature to the 5/7/21 pharmacist's recommendation, the Nurse Practitioner stated if she had seen the recommendation, she would have signed it.

Based on record reviews and staff interviews, the facility failed to provide medical justification for the use of [MEDICATION(S)] (antipsychotic medication) for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. Findings included: Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia without behavioral disturbance. Resident #8's clinical records and medication administration records revealed that on 4/29/21, the physician ordered [MEDICATION(S)] 12.5 mg (milligrams) which was administered every morning. On 4/30/21, the physician ordered [MEDICATION(S)] 25mg every 12 hours which was administered then discontinued on 5/1/21. On 5/1/21, the physician ordered [MEDICATION(S)] 25mg every evening at 5:00 p.m. which was administered. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical records revealed Resident #8 was hospitalized on [DATE] and was readmitted to the facility on [DATE] with orders for [MEDICATION(S)] 50mg every evening and 12.5mg every morning. The dosages were administered as ordered. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change minimum data set assessment dated [DATE] indicated Resident #8 was severely, cognitively impaired and was receiving an antipsychotic medication. The care plan updated 8/1/21 revealed Resident #8 was at risk for side effects from [CONDITION(S)] medications. Interventions included for staff to observe and report any side effects of the medication, report sudden change in mood or behaviors, and the pharmacist was to review the medications monthly with recommendations to the physician as needed. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #8. During an interview on 8/26/21 at 9:56 a.m., the Assistant Director of Nursing (ADON) revealed that part of the facility's communication procedure with the physician included emails from the pharmacist with medication recommendations. The Director of Nursing was responsible for ensuring the recommendations were placed in the Physician Communication book. The ADON indicated she was unsure if the physician or the nurse practitioner reviewed the pharmacist's recommendation of 5/7/21 which requested a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #8. During an interview on 8/26/21 at 2:51 p.m., the Nurse Practitioner recalled visiting Resident #8 on 7/1/21 but did not specify medical justification for the administration of [MEDICATION(S)] to the resident.

Based on record review, observation, and staff interviews, the facility failed to implement contact isolation signage for 1 of 3 residents (Resident #11) that had symptoms of [CONDITION(S)] (C-Diff) and required transmission-based precautions. The findings included: A facility policy titled Isolation - Initiating Transmission Based Precautions, revised August 2019 stated if a resident was suspected of, or identified as, having a communicable infectious disease, the nurse notifies the facility infection preventionist and the resident's attending physician for evaluation of appropriate transmission-based precautions. In the event the attending physician fails to take appropriate action, the infection preventionist has the authority to implement appropriate transmission-based precautions. The personal protective equipment (PPE) required for [MEDICATION(S)] contact precautions was a gown and gloves. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #11's most recent quarterly Minimum Data Set (MDS), dated [DATE], assessed the Resident had moderate cognitive impairment and required extensive assistance of two staff members for toileting. An interview was conducted on 8/25/2021 at 8:45 AM with Nursing Assistant (NA) #1 in the dining room. NA #1 revealed that Resident #11 was not eating in the dining room because she had two loose stools during the night and was placed on isolation precautions for suspected C-Diff. An observation was completed of Resident #11's private room on 8/25/2021 at 9:20 AM with an isolation cart containing personal protective equipment (PPE) sitting beside the doorway and no signage to indicate if isolation precautions were in place. An interview was completed with Resident #11 on 8/25/2021 at 9:21 AM with an unknown visitor sitting on Resident #11's bed with only a face mask for PPE. The Resident stated she was in her room because she was told she had a bug and was to remain in her room. The visitor denied knowing why the cart was outside of the door. An interview occurred on 8/25/2021 at 9:45 AM with Nurse #1 and she stated she was the nurse on the assignment for Resident #11. She revealed that Resident #11 had two loose stools during the night and a neighboring room had confirmed C-Diff. She added the isolation cart was placed outside of the Resident's room and a stool sample was collected in preparation for the Medical Director's (MD) visit on 8/25/2021. She stated an MD/doctor's order was required to place isolation precautions on a resident, even if the resident had a suspected communicable disease that required transmission-based precautions. She added staff were utilizing the PPE to be safe. An observation occurred on 8/25/2021 at 11:22 AM with the Director of Nursing of Resident #11's room. Nurse #1 was in the room providing personal care assistance to Resident #11 with only a face mask for PPE. When Nurse #1 exited the room, she performed hand hygiene with hand sanitizer. A PPE cart was observed beside the door to Resident #11's room and no isolation signage was present. An interview was conducted with the Director of Nursing on 8/25/2021 at 11:26 AM and she revealed Resident #11 had two loose stools during the night shift. She added that the nursing staff felt transmission-based precautions should be implemented until the Medical director could assess Resident #11 and provide orders. She stated a stool sample had been collected. She added that it was her expectation that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She added that she expected PPE to be worn into a room that had a suspected case of C-Diff. An interview was conducted on 8/25/2021 at 1:31 PM with the Assistant Director of Nursing (ADON)/Infection Preventionist for the facility. She revealed that on the morning of 8/25/2021 she received a report that Resident #11 had two loose stools and she provided instructions to Nurse #1 to implement [MEDICATION(S)] contact precautions for the Resident. She stated her expectation was for a hall nurse to carry out the instructions that included placing an isolation precaution sign on the door and a PPE cart beside the room.

Based on observations and staff interviews, the facility failed to post the results of the most recent survey of the facility. Findings included: The Aspen Central Office database system was reviewed and revealed the most recent survey at the facility was a focused infection control survey completed on 11/24/20. During a tour of the facility on 8/24/21 at 9:07 AM and 8/25/21 at 1:30 PM, observations were made of survey results located in a three ring binder notebook on a credenza in the entryway of the facility. The most recent survey results in the notebook were from 8/8/19. During the Resident Council group meeting on 8/25/21 at 2:03 PM, the residents indicated they were aware of the location of the survey results in the entryway of the facility. An interview was completed with the Administrator on 8/26/21 at 10:25 AM. The survey results notebook was reviewed with the Administrator and revealed the most recent survey results in the notebook were from 8/8/19. The Administrator said he was new to the facility and was set up to receive the statement of deficiencies when a survey was completed by the State Agency. He added it was his responsibility to ensure the survey results were placed in the notebook. He said the most recent survey dated 11/24/20 should have been included in the survey results notebook and was unsure why the previous administration had not placed them in the notebook.

Based on record reviews and staff interviews, the facility failed to provide written notifications to the residents and the resident representatives of the reason for the transfers of 2 of 2 sampled residents (Residents #4 and #21) to the hospital. The facility failed to provide written notification to the ombudsman of the transfer of 1 of 2 sampled residents (Resident #4) to the hospital. Findings included: 1. Resident #4 was admitted to the facility on [DATE]. The quarterly minimum data set assessment dated [DATE] indicated Resident #4 was moderately, cognitively impaired. The medical record revealed Resident #4 was transferred to the hospital on 7/14/21 due to a critically low hemoglobin laboratory result. The record indicated the resident's family member was notified. The resident was readmitted to the facility on [DATE]. No written notice of transfer was documented to have been provided to the resident, the resident's representative, or the ombudsman. A clinical note in the medical record on revealed Resident #4 was transferred to the hospital on 7/29/21 due to complaints of abdominal pain and abnormal laboratory values. The resident was readmitted to the facility on [DATE]. There was no documentation indicating a written notice of transfer was provided to the resident, the resident's representative, or the ombudsman. During an interview on 8/26/21 at 1:03 p.m., the Administrator acknowledged the facility did not provide a transfer/discharge notice to the resident, the resident's representative or to the ombudsman. During an interview on 8/26/21 at 1:25 p.m., the Assistant Director of Nursing (ADON) revealed that during the interim of the facility's social worker's replacement, she was responsible for notifying ombudsman of the transfer/discharge of residents. She indicated she would submit a list of resident transfers/discharges to the ombudsman by the 15th of the following month. She stated Resident #4 was mistakenly left from the August 2021 list sent to the ombudsman. The ADON also revealed she was not aware a written notification of a resident's discharge/transfer was to be sent to the resident's representative. 2. Resident #21 was admitted to the facility on [DATE]. The admission minimum data set assessment dated [DATE] indicated Resident #21 was moderately, cognitively impaired. The medical record revealed Resident #21 was transferred to the hospital on 8/14/21 for evaluation and treatment due to labored breathing, low oxygen saturation and low blood pressure. The resident passed away at the hospital on 8/15/21 due to metastatic lung cancer. No written notice of transfer was documented to have been provided to the resident or the resident's representative. During an interview on 8/26/21 at 1:03 p.m., the Administrator acknowledged the facility did not provide a transfer/discharge notice to the resident or the resident's representative. During an interview on 8/26/21 at 1:25 p.m., the Assistant Director of Nursing (ADON) revealed that during the interim of the facility's social worker's replacement, she was responsible for notifying ombudsman of the transfer/discharge of residents. She indicated she would submit a list of resident transfers/discharges to the ombudsman by the 15th of the following month. She stated Resident #21 would be included on the August 2021's discharge/transfer notification list which would be sent to the ombudsman by 15th of September 2021. The ADON revealed she was not aware a written notification of a resident's discharge/transfer was to be sent to the resident's representative.

Based on record reviews and staff interviews, the facility failed to complete and transmit Discharge Tracking MDS (Minimum Data Set) assessments within the required time frame for 5 of 6 residents (Resident #1, #2, #3, # 4, and # 5) selected to be reviewed for submission of Resident Assessments within the required time frame. Findings included: 1. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 1's most recent completed MDS was dated [DATE]. The assessment was coded as an admission assessment. A review of Resident # 1's face sheet had resident as being discharged on [DATE]. During an interview on [DATE] at 5:30 pm with the MDS coordinator, she indicated the resident had expired in the facility on [DATE]. She further added an assessment had been started but not completed. She explained that the nurse that was doing the assessment was no longer employed by the facility and she could not speak to why the assessment was not completed. She stated one should have been completed on [DATE] and that she would complete and transmit the assessment. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 2's most recent completed MDS was dated [DATE]. The assessment was coded as an admission assessment. A review of Resident # 2's face sheet had resident as being discharged on [DATE]. During an interview on [DATE] at 5:30 pm with the MDS coordinator, she indicated the resident was discharged on [DATE]. She further added an assessment had been started but not completed. She stated a discharge tracking assessment should have been completed on [DATE] and that she would complete and transmit the assessment. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 3's most recent completed MDS was dated [DATE]. The assessment was coded as a PPS unscheduled assessment. A review of Resident # 3's face sheet had resident as being discharged on [DATE]. During an interview on [DATE] at 5:30 pm with the MDS coordinator, she indicated the resident went home with home health [DATE]. She further added an assessment had been started but not completed. She stated a discharge tracking assessment should have been completed on [DATE] and that she would complete and transmit the assessment. 4. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident # 4's most recent completed MDS was dated [DATE]. The assessment was coded as a PPS 14-day assessment. A review of Resident # 4's face sheet had resident as being discharged on [DATE]. During an interview on [DATE] at 5:30 pm with the MDS coordinator, she indicated the resident was discharged to the hospital on [DATE]. She further added an assessment had been started but not completed. She stated a discharge tracking assessment should have been completed on [DATE] and that she would complete and transmit the assessment. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident # 5's most recent completed MDS was dated [DATE]. The assessment was coded as a PPS 14-day assessment. A review of Resident # 5's face sheet had resident as being discharged on [DATE]. During an interview on [DATE] at 5:30 pm with the MDS coordinator, she indicated the resident was discharged to the hospital on [DATE]. She further added an assessment had been started but not completed. She stated a discharge tracking assessment should have been completed on [DATE] and that she would complete and transmit the assessment. During an interview with the DON (Director of Nursing), who was also present during the interview with the MDS coordinator, on [DATE] at 5:50 pm, the DON stated she expected all required MDS assessments be completed and transmitted within the required time frame.