Every finding on record at Ignite Medical Resort San Antonio, LLC

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #3 and Resident #5) reviewed for infection control. The facility failed to ensure RN D followed Enhanced Barrier Precautions when providing wound care to Resident # 3 on 3/26/26. The facility failed to ensure RN D followed Enhanced Barrier Precautions when providing wound care to Resident #5 on 3/26/26. The facility failed to ensure RN D followed infection control practices when providing wound care to Resident #3 on 3/26/26. The facility failed to ensure RN D followed infection control practices when providing wound care to Resident #5 on 3/26/26. These failures could affect all residents who require wound care, placing them at risk for infection. Findings included: 1. Record review of Resident #3's admission Record, dated 4/2/26, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Osteomyelitis (serious infection of the bone), muscle weakness, and need for assistance with personal care. Record review of Resident #3's Care Plan, dated 2/17/26, revealed the resident had actual impairment to skin integrity. Further review revealed interventions included Follow facility protocols for treatment of injury. Record review of Resident #3's Order Summary, dated 4/2/26, revealed orders for: Wound care to coccyx area as follows: Cleanse with NS on gauze, pat dry with gauze, apply nickel thick Santyl ointment (a prescription ointment used to remove dead tissue form skin ulcers)and gently pack with hydro [NAME] blue (an antibacterial foam dressing that provides protection against bacteria), cover with foam dressing q daily and PRN, dated 2/17/26. Further review of this document revealed an order for Enhanced Barrier Precautions, dated 2/10/26. Observation of wound care for Resident #3's coccyx area, on 3/26/26 beginning at 11:45 am, revealed RN D entered Resident #3's room without donning a gown and proceeded to perform wound care to the resident's coccyx area. Further observation revealed there was no EBP sign or PPE outside the resident's room. 2. Record review of Resident #5's admission Record, dated 3/31/26, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: surgical aftercare following surgery on the circulatory system, sepsis (life-threatening complication of an infection), muscle weakness, and need for assistance with personal care. Record review of Resident #5's Care Plan, dated 3/11/26, revealed the resident was on Enhanced Barrier Precautions related to wounds. Record review of Resident #5's Order Summary, dated 3/31/26, revealed orders for: Wound care to coccyx area as follows: Cleanse with NS, pat dry with gauze, apply betadine to peri wound, nickel thick Santyl ointment (a prescription ointment used to remove dead tissue form skin ulcers) and calcium alginate (highly absorbent wound dressing) to wound bed, cover with foam dressing q daily and PRN, dated 3/20/26; Wound care to left and right groin surgical incision as follows: Cleanse with Dakins 1/4 solution, pat dry with gauze, apply betadine to peri wound, nickel thick Santyl ointment (a prescription ointment used to remove dead tissue form skin ulcers) nystatin powder (antifungal medication), and calcium alginate (highly absorbent wound dressing) to wound bed, cover with dressing q daily and PRN, dated 3/31/26 Observation of wound care for Resident #5's coccyx area and groin areas, on 3/26/26 beginning at 11:15 am, revealed RN D entered Resident #5's room without donning a gown and proceeded to perform wound care to the resident's coccyx and groin areas. Further observation revealed there was no EBP sign or PPE outside the resident's room. During an interview on 3/26/26 at 12:34 pm, RN D said EBP were required when she provided wound care and would have to wear gown, gloves, mask and perform hand hygiene depending on what the protocols were. RN D further stated she had not been told she had to donn PPE for wound care unless the wound was infected and the resident was on isolation for the wound. RN S said it was important to follow EBP during wound care to prevent the spread of infection into the wounds or have bodily fluids get on the staff and spread to other residents. Observation of wound care for Resident #3's coccyx area, on 3/26/26 beginning at 11:45 am, revealed RN D cleaned Resident #3's wound, applied treatment, packed the wound, and applied foam dressing without performing hand hygiene or changing gloves after cleaning the wound and before applying treatments and dressing. Observation of wound care for Resident #5's groin areas, on 3/26/26 beginning at 11:15 am, revealed RN D cleaned the wound to right groin then the left groin without removing gloves, performing hand hygiene, and donning clean gloves between areas. Further observation revealed RN D applied treatments and dressing to the right groin, without removing gloves, performing hand hygiene and donning clean gloves. RN D then applied treatment and dressing to the wound to the left groin without performing hand hygiene and still wearing the same gloves. During an interview on 3/26/26 at 12:34 pm, RN D said she was required to change gloves and perform hand hygiene when going form dirty to clean, adding she was expected to remove her gloves, perform hand hygiene, and donn clean gloves after cleaning a wound. RN D further stated she was expected to change gloves and perform hand hygiene when going from one wound to another. RN D said she had not realized that she did not change gloves when going from wound to wound during Resident #5's wound care. RN D said this was important to prevent the spread of infection, contamination, and the safety of the residents. RN D further stated all staff were responsible for infection control. During an interview on 4/2/26 at 4:12 pm, ADON B said EBP were required anytime there were tubes extending from outside of the body to the inside and wounds. ADON B further stated it was everyone's responsibility to follow EBP. ADON B said it was important to follow EBP to protect the staff and the residents from any organisms that may cause infections. ADON B said staff were expected to perform hand hygiene anytime gloves have been soiled. ADON B further stated once a wound had been cleaned, staff should remove their gloves and perform hand hygiene, gloves should be removed and hands sanitized before applying treatments and dressings. ADON B said this was important for infection control, to prevent cross contamination. The DON was not available during the investigation. Record review of the facility's policy titled Hand Hygiene, revised April 2023, revealed: .Hand-washing may also be used for routinely decontaminating hands in the following clinical situations.After removing gloves.If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands in the following clinical situations.After removing gloves.Change gloves during resident care if moving from a contaminated body site to a clean body site. Decontaminate hands after removing gloves by appropriate hand hygiene. Record review of the facility's policy titled Wound Policy & Procedure last revised 05/2023, revealed: .General infection control practices are maintained during wound care and dressing changes. Record review of the facility's policy titled Enhanced Barrier Precautions dated March 2024, revealed: Policy: This facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI).Enhanced Barrier Precautions (EBP) are implemented as one intervention this facility uses to reduce transmission of resistant organisms that employs targeted Personal Protective Equipment (PPE) use during high contact resident care activities.EBP is used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP will be used for any residents in this facility who meet the stated criteria wherever the resident resides in the facility.residents with the following conditions require EBP for all cares and services regardless of MDRO colonization status: Wounds including any skin opening requiring a dressing regardless of MDRO colonization status. Record review of the facility's policy titled Infection Control last revised May 2024, revealed: .Perform hand hygiene.Immediately after touching blood, body fluids, non-intact skin, mucous membranes or contaminated items (even when gloves are worn during contact), immediately after removing gloves, when moving from contaminated body sites to clean body sites during resident care.

Based on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (TC #1) reviewed for medication storage. The facility failed to ensure the treatment cart in the public area was locked on 3/25/26. This failure could place residents at risk of medication misuse and drug diversion. Findings included: During observation on 3/25/26 at 1:38 pm, TC #1 was observed to be unlocked and unattended on the 100 hall by the state investigator. Further observation revealed the resident room the TC was in front of was closed. Observation revealed wound cleanser, iodine, and wound care supplies in the drawers of TC #1. There were 3 staff in black uniforms assisting residents in the hallway and the TC was not within view of the nurses' station. During an interview on 3/25/26 at 1:40 pm RN A said he had only gone inside the resident's room for 2 minutes. RN A further stated he was not supposed to leave TC #1 unlocked because there were treatments and medication in the cart. RN A further stated it was important that unattended carts be locked when unattended because a resident may go in the cart and access the contents. During an interview on 3/26/26 at 1:04 pm PTA C said the facility therapists wore black uniforms. During an interview on 4/2/26 at 4:12 pm, ADON B said treatment carts were supposed to be locked because there were scissors, and medications in the carts that may be dangerous to guests, staff, and residents. ADON B said the facility had a lot of people walking around, and the treatment cart should be treated just like a medication cart. ADON B further stated whoever was assigned the cart was responsible for ensuring it was locked when unattended, but that any staff can lock medication cart if they were seen unlocked when unattended. The DON was not available during the investigation. Record review of the facility's policy titled, Medication Storage dated 2007, revealed: .Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 1 of 1 facility reviewed for competent staffing. The facility failed to complete annual performance reviews for CNAs employed by the facility for 1/1/2025 through 9/1/2025.This failure could lead to incompetent staff and improper care to residents. Findings included: Record review of the facility staff roster provided by the HR Dir on 9/23/2025 reflected 35 CNA staff members. Of the 25 CNAs, 25 were eligible for an annual performance review in that they had been employed by the facility for over one year and had a month of hire occurring from January through September. In an interview with HR Dir. on 9/24/2025 at 8:35 AM, she stated the facility did not have a formal process for annual reviews. She said informal, periodic performance evaluations were completed by the nursing managers and issues were addressed as they occurred. She said the performance evaluations were not documented. In an interview with CNA C on 9/24/2025 at 9:03 AM, she said she had worked at the facility for 6 years. She said she had not participated in an annual performance review with the nursing leadership. In an interview with the DON on 9/24/2025 at 9:20 AM, she said there is not a formal, annual performance review process. She said the ADONs will meet with staff members and take notes on any concerns, and they use the notes to determine any training needs. She said the notes taken during any meetings with staff about performance were not documented in the employment records. Record review of the facility policy titled Performance Evaluation (undated, received 9/24/2025) revealed the following: In order to satisfactorily complete your duties and responsibilities, communication and constructive feedback are key parts in doing so. Employees of [facility] will be evaluated on their anniversary date. Between scheduled evaluations, informal performance discussions may be held between you and your supervisor to discuss your performance.

Based on observations, interviews, and record reviews the facility failed to ensure the resident environment remained free of accident hazards as is possible for 1 of 1 laundry departments (2 of the 3 dryers) reviewed for fire hazards.The facility failed to clean out the lint from the 2 commercial dryer's interiors for a year.This failure could place residents at risk for a potential fire. The findings included: During an observation on 9/23/2025 at 2:41 PM revealed the facility's laundry department had 2, natural gas fueled, commercial dryers. The mechanical back of the dryers were housed in an enclosed room accessed by a wood frame door. Observation of the room revealed the back of the dryers which included electrical connections, natural gas connections, and electrical motors with pulleys and rubber belts. Further observation revealed the dryers were operating and the flames from the burners used to heat the air could be visualized inside the machines. Further observation revealed a layer of dust / lint lining the interior of the machines, the exterior of the machines, and covered the electrical motors which drove the machines clothing tumblers. During an interview on 9/23/2025 at PM Laundry Aide P stated she cleaned the lint from the front side of the commercial dryers everyday but had not been assigned to clean out the back of the machines. During an observation and interview on 9/24/2025 at 9:10 AM the Maintenance Director toured the laundry department and stated he was also the laundry department supervisor. The Maintenance Director stated the commercial dryers had their mechanical rears enclosed in a room accessed by a door directly behind the dryers. The Maintenance Director demonstrated the door and reviewed the room which housed the dryers. The Maintenance Director stated the machines were covered with a layer of lint / dust throughout the interior and exterior of the machines. The Maintenance Director stated the machines had not been cleaned out from their rear in the past year. The Maintenance Director stated the machines needed to be cleaned out immediately and suspended their use. During an interview on 9/24/2025 at 1:00 PM the Maintenance Director stated he had dismantled the dryers and cleaned them of their lint dust and had placed them back in service. The Maintenance Director stated he would add the task of cleaning the dryers to the facility's monthly tasks and keep documents of their cleaning. The Maintenance Director stated the lint dust build up could possibly contribute to a fire. A policy was requested on 9/24/2024 from the Administrator and as of 9/29/2025 a policy was not provided. A record review of the commercial dryers undated manufactures maintenance manual revealed, Quarterly1. Use a vacuum to clean air vents on drive motors.5. Clean the machine's top panel with mild detergent. Rinse with clean water.6. Models equipped with a fire suppression system: Perform the fire suppression system maintenance test by pressing the test button in the control box. Bi-Annually2. Check gas connections for leakage.6. Remove all front panels and vacuum, .9. Clean burner tubes and orifice area of any lint buildup.Annually1. Remove burner tubes.2. Clean burner tubes using water and a brush.Fire Suppression System (Optional Equipment) Maintenance TestNOTE: Fire suppression system only available on gas and steam models.To ensure proper operation, the fire suppression system must be tested every three months. If the system test does not perform as indicated:1. Discontinue use of the tumble dryer.2. Refer to Troubleshooting Manual or contact a qualified serv ice person.3. Restore the fire suppression system to proper working order before using tumble dryer.Create a maintenance record with a check box for pass, the date and a signature. Store this record in an area where it will not be damaged but is easily accessible to person performing tests.NOTE: Failure to maintain the fire suppression system will void the tumble dryer warranty.NOTE: The auxiliary output is activated during the fire suppression system maintenance test sequence. Con [NAME] this fact prior to testing the system every three months. (Example - If the external system uses the auxiliary output to call the fire department, inform the fire department before and after the fire suppression system maintenance test.)

Based on observation, interview, and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 3 of 3 LVNs (ADON A, LVN F, and LVN G) reviewed for staff competency. The facility failed to ensure ADON A, LVN F, and LVN G were competent and trained to provide care for Resident #108's PleurX [a catheter placed in the chest cavity for long-term drainage]. This failure could lead to improper care and complications of Residents' medical care.Findings included: Record review of Resident #108's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included resistance to vancomycin related antibiotics, malignant pleural effusion [a fluid collection in the space surrounding the lung], and secondary malignant neoplasm of unspecified lung [lung cancer]. Record review of Resident #108's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Section I0100 indicated Resident #108 had an active diagnosis of cancer, and section OD. of the MDS reflected 0 minutes of respiratory therapy treatments were administered to Resident #108 in the last 7 days. Record review of Resident #108's Order Summary Report dated 9/22/2025 reflected the following active orders: Drain pleurx drain [a catheter inserted into the chest to allow for repeated drainage of fluid] to R-front quad (R-lung) one time a day on even days for drain every other day [sic] (date ordered 9/20/2025, start date 9/22/2025) Record review of Resident #108's care plan report printed 9/22/2025 did not reflect care planning for the PleurX draining procedure. Record review of Resident #108's progress notes reflected nursing documentation indicating Resident #108 was transferred to the emergency department on 9/12/2025 at 12:00 PM for abnormal laboratory results. An additional progress note documented on 9/18/2025 at 6:44 PM reflected Resident #108 returned to the facility and that Resident #108 refused a full skin assessment and weight after arrival. Record review of Resident #108's hospital discharge paperwork dated 9/17/2025 reflected the PleurX catheter had been accessed and drained by hospital staff on 9/16/2025. Record review of a physician's progress note dated 9/19/2025 at 12:00 PM reflected the following: ASSESSMENT AND PLAN:,,,# Lung cancer with mets to throat# squamous cell carcinoma [a type of skin cancer]# recurrent malignant right plural effusion-Plurex drain management by nursing staff, drain as ordered, and PRN, continue lasix, nebs, monitor weights-Follow up oncology and pulmonology [sic] Further record review of Resident #108's progress notes did not reveal documentation from nursing staff accessing and draining the PleurX from 9/18/2025 through 9/22/2025. Record review of Resident #108's September 2025 TAR, dated 9/23/2025, reflected the following:Right pulmonary drain: drain every other day one time a day every other day for pulmonary drain/ edema drain every other day [sic] (order date 9/03/2025 2:46 AM, D/C date 9/15/2025 5:19 PM)9/4/2025 8:00 AM: treatment performed, output documented as XmL (ADON J)9/6/2025 8:00 AM: treatment performed, output 50mL (ADON J)9/8/2025 8:00 AM: treatment performed, output NA (LVN F)9/10/2025 8:00 AM: treatment performed, output 50mL (LVN F)9/12/2025 8:00 AM: treatment performed, output 50mL (LVN F)9/14/2025 8:00 AM: other/see nurse's notes (LVN F)Record review of Resident #108's September 2025 NMAR, dated 9/23/2025, reflected the following:9/18/2025: no order to drain the PleurX9/20/2025: no order to drain the PleurXDrain pleurx drain to R-front quad (R-lung) one time a day on even days for drain every other day (order start 9/22/2025) 9/22/2025 12:00 PM: drug refusedRecord review of Resident #108's documented vital signs for 9/18/2025 through 9/22/2025 reflected no abnormalities in oxygen saturations or respiratory rates. In an observation and interview on 9/21/2025 at 12:34 PM, a coiled catheter was observed to Resident #108's right, lower chest area with a clean, intact dressing dated 9/16/2025. Resident #108 said the catheter had not been accessed since she returned to the facility from the hospital on 9/18/2025. She stated she had been told by multiple unknown nursing staff that they could not drain the catheter because they did not know how. She said an unknown staff member had told her yesterday (9/20/2025), that the catheter would be drained today (9/21/2025). Resident #108 said she asked the staff about the draining procedure because she was aware of the physician's order to drain the catheter every other day, and she was aware the schedule was not being followed. She said she did not feel any increase in symptoms even though the catheter had not been drained since before 9/18/2025. Resident #108 denied shortness of breath, chest pain/pressure, or difficulty breathing during the interview. In an interview on 9/23/2025 at 8:31 AM, LVN G said he was the primary nurse for Resident #108, and he was informed during change of shift report that Resident #108 had a PleurX with scheduled draining procedures occurring every five days. He said the next scheduled procedure was on 9/22/2025. LVN G was unaware the physician's order for the PleurX catheter directed nursing staff to perform the procedure every other day, and he stated he would clarify with the physician. He was unsure when the PleurX was last drained. LVN G stated he was hired at the facility approximately 1 month before and did not receive training from the facility on PleurX catheters. He said he felt comfortable accessing Resident #108's PleurX, if needed, because he had prior experience at a different facility. In an interview with ADON A on 9/23/2025 at 12:30 PM, she said she was the primary nurse for Resident #108 on 9/22/2025. She said Resident #108 informed her on 9/22/2025 that the PleurX had been drained on 9/21/2025, but ADON A did not verify this information with the medical record. She said Resident #108 then told her she would prefer to have the PleurX drained every 5 days and did not want the procedure done that day. ADON A said she had forgotten to contact the provider to discuss the request and obtain a modified order for the new frequency. ADON A said she felt comfortable providing care for a PleurX catheter, and she had previously received training for PleurX catheters from the facility. She said training was provided to nursing staff only as needed, but the facility did not document the training. She said she expected that facility would not perform the PleurX procedure if they did not have adequate training, but she was unsure how the facility would ensure the treatment had been performed correctly if not all staff had received training. ADON A then said there was no potential harm to Resident #108's chest tube [an alternative descriptor of the device] because the catheter was inserted into Resident #108's abdomen. ADON A clarified that a chest tube is inserted into a person's chest, but Resident #108 had a catheter in her abdomen. ADON A was unable to recall Resident #108's diagnosis that led to the need for a long-term drainage device. In an interview on 9/23/2025 at 3:23 PM, LVN F stated she had accessed and drained Resident #108's PleurX catheter several times in September. She said she had not received training from the facility for PleurX catheters, and she was shown how to perform the procedure by another nurse who was working that day. She said this was the only nurse in the building who knew how to access the PleurX. She was not aware the procedure was to be performed using sterile technique and had not utilized sterile technique on any of the procedures she performed for Resident #108. In an interview with the DON on 9/24/2025 at 8:05 AM, she said the training and skills validation for nursing staff caring for a PleurX was not included on the new hire or annual curriculum. She stated any staff who had not been trained on PleurX catheters are expected to reach out to herself or the nursing leader on call in order to receive training before accessing a PleurX. She said she had not been contacted by any staff for PleurX training since Resident #108 had admitted to the facility. She was unaware that the PleurX draining procedure was not included in Resident #108's care plan, and she felt the task should have been included. She said she was jointly responsible for the care plan with the ADONs and MDS nurse. She was unaware that Resident #108 did not have an order to drain the PleurX on 9/18/2025 or 9/20/2025, and she was unaware Resident #108 had been allegedly refusing the procedure. Record review of the facility document titled Licensed/Registered Nurse Competency Validation Checklist (undated, received 9/23/2025) did not reveal PleurX or chest tubes as a training topic. Record review of the facility policy titled Pleurx Drain Care [sic] revised 9/2024, revealed the following: All procedures must follow aseptic technique and manufacturer guidelines . Review resident's comprehensive care plan for instructions All staff must complete initial and annual competency validation .

Number of residents sampled: Number of residents cited: Based on the interview and record review, the facility failed to ensure that 1 of 8 residents (Resident # 87) reviewed for medication errors was free of any significant medication errors. The facility failed to administer the prescribed medication (Potassium & Sodium Phosphates Oral Packet 280-160-250 MG) for low potassium and sodium to Resident #87. This deficient practice could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and a decline in health. The findings included: Record review of admission face sheet, dated 9/22/2025, revealed Resident # 87 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included Type two diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and Anxiety Disorder (excessive fear of or apprehension about real or perceived threats, leading to altered behavior) and Hypertension (is a chronic medical condition characterized by persistently elevated blood pressure). Record review of the quarterly MDS assessment, dated 9/22/2025, revealed Resident # 87 had a BIMS score of 15, which indicated intact cognition. Record review of physician orders for September 2025 revealed that Resident # 87 had the following order: Phosphates Oral Packet 280-160-250 MG, give one packet by mouth with meals 7:30 a.m., 11:30 a.m., and 1:30 p.m. Review of the medication administration record for Resident # 87 from 9/16/25 to 9/23/25 revealed 18 missed doses of Phosphates Oral Packet 280-160-250 MG, which were documented as medication unavailable. Record review of Labs for Resident # 87, dated 9/23/25, drawn on 9/21/25, revealed potassium and sodium levels to be within range. Record review of Resident #87's physician's orders for 9/16/25 -9/23/25 did not reveal any orders to hold Phosphates Oral Packet 280-160-250 MG; however, the order was discontinued on 9/23/25 at 10:55 a.m., after surveyor intervention. Interview on 9/23/2025 at 11:35 A.M., Resident # 87 stated she had not received the Phosphates Oral Packet 280-160-250 MG since admission on [DATE] but felt she did not need it . Interview with MA (I) on 9/23/25 at 9:18 AM stated she did not know the medication was not available until the surveyor's intervention, as this was her first day back after being off for five days and had not worked the side Resident # 87 was on since prior to her admission . MA (I) confirmed that she was aware that if a medication is missing, she is to inform the charge nurse, who then calls the pharmacy and notifies the DON. Interview with LVN (G) on 9/23/25 at 9:40 AM stated he was unaware that Resident #87 was missing doses of medication Phosphates Oral Packet 280-160-250 MG, until MA (I) brought it to his attention earlier today. LVN (G)stated he called the physician and informed him of the missing doses for Resident #87, including labs being within range, and the physician discontinued the order for Phosphates Oral Packet 280-160-250 MG. LVN (G) stated Resident # 87 risked labs being out of normal limits if medication was missed; however, this was not the case this time. Interview with the DON on September 24, 2025, at 8:45 A.M. revealed that the pharmacy did not send the medication for Resident #87 because it was considered over-the-counter on 9/16/25 and required authorization from the DON ( she was never informed). The DON stated that she was unaware that Resident #87 was missing Phosphates Oral Packet (280-160-250 mg) until LVN (G) notified her on September 23, 2025. Had she known earlier, she would have authorized the delivery of the supplement. The DON explained that licensed nurses are responsible for informing her and the pharmacy if any medication is missing, so she can follow up on why the pharmacy did not send it. While she noted she did not have a policy to address this because it was considered a process, she mentioned that she would randomly monitor all MAs in the facility to ensure compliance regarding missing medications.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Residents #52, #53, #87, #108, and #121) reviewed for infection control. The facility failed to ensure enhanced-barrier precautions were initiated for Residents #52, #53, #87, and #121.The facility failed to ensure contact isolation precautions were initiated for Resident #108 when she admitted to the facility on antibiotic therapy for blood culture results positive for VRE (a contagious bacterial infection that is resistant to multiple antibiotics). These failures could lead to the spread of infection and illness. Findings included: 1. Record review of Resident #52's face sheet dated 9/22/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included encounter for surgical aftercare following surgery on the circulatory system and burn of unspecified degree of right thigh, subsequent encounter. Record review of Resident #52's Order Summary Report dated 9/22/2025 reflected an order dated 9/11/2025 for enhanced barrier precautions. Record review of Resident #52's care plan report, printed 9/22/2025, reflected the following:[Resident #52] is on Enhanced Barrier Precautions [a type of isolation precaution requiring special protection to staff when caring for a resident] related to chronic wounds (pressure ulcers, diabetic ulcers), colonization or infection with MDRO(s), ostomy [a surgically created opening in the skin], IV therapy, dialysis and or presence of an indwelling device(s) such as central venous catheter, indwelling urinary catheter, tracheostomy, feeding tube [sic] . date initiated 9/14/2025Record review of Resident #52's MDs assessments revealed no submissions of a BIMS score assessment as of 9/22/2025. In an observation and interview on 9/21/2025 at 1:03 PM, Resident #52's room was observed without posted signage indicating Resident #52 required EBP. No PPE cart was present in the hallway in front of the door. Resident #52 said she was admitted to the facility for care after her heart surgery, and a surgical wound was observed on Resident #52's chest. Resident #52 also said she had a wound to her right thigh, and a wound was observed on the back of her leg, above the knee. Record review of Resident #53's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included sepsis [an infection that has spread into the bloodstream], unspecified organism and urinary tract infection, site not specified. Record review of Resident #53's Order Summary Report dated 9/21/2025 reflected an order dated 9/11/2025 for enhanced barrier precautions. Record review of Resident #53's care plan report, printed 9/21/2025, did not reveal care planning for enhanced barrier precautions. Record review of Resident #53's MDs assessments revealed no submissions of a BIMS score assessment as of 9/21/2025. In an observation and interview on 9/21/2025 at 11:18 AM, Resident #53's room was observed without posted signage indicating Resident #53 required EBP. No PPE cart was present in the hallway in front of the door. Resident #53 exhibited confusion during the interview and was not able to provide reliable information regarding the clinical care provided by the facility. Record review of Resident #87's face sheet, dated 9/22/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included encounter for surgical aftercare following surgery on the circulatory system and dependence on renal dialysis [a procedure that filters the blood due to kidney disease]. Record review of Resident #87's Order Summary Report dated 9/22/2025 reflected an order dated 9/15/2025 for enhanced barrier precautions. Record review of Resident #87's care plan report, printed 9/22/2025, reflected the following:[Resident #87] is on Enhanced Barrier Precautions related to chronic wounds (pressure ulcers, diabetic ulcers), colonization or infection with MDRO(s), ostomy, IV therapy, dialysis and or presence of an indwelling device(s) such as central venous catheter, indwelling urinary catheter, tracheostomy, feeding tube . date initiated 9/16/2025 Record review of Resident #87's MDs assessments revealed no submissions of a BIMS score assessment as of 9/21/2025. In an observation and interview on 9/22/2025 at 9:33 AM, Resident #87's room was observed without posted signage indicating Resident #53 required EBP. No PPE cart was present in the hallway in front of the door. Resident #87 said she received dialysis treatments from the facility five days a week via catheter. A dialysis catheter was observed to Resident #87's right chest with a clean, intact dressing dated 9/22/2025 covering the insertion site. In an interview on 9/24/2025 at 6:59 AM, CNA C stated Resident #87 did not require any TBP precautions. CNA C said that when she worked, she knew which residents required TBP based on the signs posted outside of their rooms and from report given by other staff at shift change, and since Resident #87 did not have a sign, she knew the resident was not on TBP. Also, she was not told by the overnight CNA during shift change about TBP for Resident #87. Record review of Resident #121's face sheet, dated 9/22/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included urinary tract infection, site not specified and cognitive communication deficit. Record review of Resident #121's Order Summary Report dated 9/22/2025 reflected an order dated 9/10/2025 for enhanced barrier precautions. Record review of Resident #121's care plan report, printed 9/22/2025, reflected the following:[Resident #121] is on Enhanced Barrier Precautions related to chronic wounds (pressure ulcers, diabetic ulcers), colonization or infection with MDRO(s), ostomy, IV therapy, dialysis and or presence of an indwelling device(s) such as central venous catheter, indwelling urinary catheter, tracheostomy, feeding tube . date initiated 9/21/2025 Record review of Resident #121's MDs assessments revealed no submissions of a BIMS score assessment as of 9/22/2025. In an observation on 9/21/2025 at 3:35 PM, Resident #121's room was observed without posted signage indicating Resident #53 required EBP. No PPE cart was present in the hallway in front of the door. 2. Record review of Resident #108's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included resistance to vancomycin related antibiotics, malignant pleural effusion [a fluid collection in the space surrounding the lung], and secondary malignant neoplasm of unspecified lung [lung cancer]. Record review of Resident #108's Order Summary Report dated 9/22/2025 reflected an order dated 9/22/2025 that read as follows:Drain pleurx drain [a catheter inserted into the chest to allow for repeated drainage of fluid] to R-front quad (R-lung) one time a day on even days for drain every other day [sic] Resident #108's Order Summary Report did not reflect an order for EBP.Record review of Resident #108's care plan report, printed 9/22/2025, reflected the following:[Resident #52] is on Enhanced Barrier Precautions related to chronic wounds (pressure ulcers, diabetic ulcers), colonization or infection with MDRO(s), ostomy, IV therapy, dialysis and or presence of an indwelling device(s) such as central venous catheter, indwelling urinary catheter, tracheostomy, feeding tube [sic] . date initiated 9/04/2025 Record review of Resident #108's hospital discharge paperwork dated 9/17/2025 revealed a discharge report from a hospitalist 9/17/2025 that indicated Resident #121's blood samples were cultured and grew VRE sensitive to linezolid (an antibiotic), and she was subsequently evaluated while in the hospital for VRE bacteremia. In an observation and interview on 9/21/2025 at 12:34 PM, Resident #108's room was observed without posted signage indicating Resident #53 required TBP. No PPE cart was present in the hallway in front of the door. A coiled catheter was observed to Resident #108's right, lower chest area with a clean, intact dressing dated 9/16/2025. Resident #108 said the catheter had not been accessed since she returned to the facility from the hospital on 9/18/2025. In an observation and interview on 9/23/2025 at 8:31 AM, a sign was observed on Resident #108's door frame indicating Resident #108 required EBP precautions. LVN G said Resident #108 should be on contact precautions due to the opening in her skin. He was unaware of Resident #108's diagnosis of VRE. LVN G also said any resident requiring TBP should have a posted sign and PPE cart in front of the room door. He said the potential harm to residents from not having TBP signage posted, or proper PPE was infection. In an interview with the DON on 9/24/2025 at 8:05 AM, she identified herself as the staff member serving as the Infection Preventionist for the facility. She said the facility uses a tracking device to monitor ordered TBP precautions, and it is the responsibility of the ADONs to monitor their respective floors on a daily basis for compliance with the orders. She was unaware of Resident #108's diagnoses of VRE, and said Resident #108 should have been on contact isolation precautions based on the diagnosis. The DON also said she was unaware of the missing TBP signage and PPE carts for Residents #52, #53, #87, and #121. She said the signage and PPE carts should have been implemented as soon as staff became aware of the need for TBP. She said the need for TBP was identified during the admission assessment by the nursing staff or orders from the referral source. She reported the potential harm to residents from not having properly implemented TBP was infection. Record review of the facility policy titled Infection Control Policy dated 9/2022 revealed the following:The resident's clinical record and door will display the appropriate isolation notification by nursing staff .When a resident is placed on transmission-based precautions, facility's Infection Preventionist [sic] will implement the following but is not limited to: .Make PPE readily available near the entrance to the resident's room .Contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such as multi-drug resistant organism .

Based on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (200-hall medication cart), reviewed for security. LVN G left the 200-hall west medication cart unattended and unlocked. This failure could place residents at risk for having their medications accessible to unauthorized people. The findings included: During an observation and interview on 9/23/2025 at 10:43 AM revealed the 200-hall west medication cart parked in the 200-hall west hallway unlocked and unattended. Further review revealed staff and residents ambulated nearby in the hallway. During an interview on 9/23/2025 at 10:45 AM ADON J stated the cart was assigned to LVN G. ADON J stated the expectation was for the medication carts to be locked when not attended. During an interview on 9/23/2025 at 10:49 AM LVN G stated he was in a resident's room assessing their blood sugar. LVN G stated he could not see his medication cart from within the residents' room because he provided privacy for the Resident and had the residents room door closed. LVN G stated he left the medication cart unlocked because of human error. LVN G stated a potential negative outcome could be loss of control of residents' medications. During an interview on 9/24/2025 at 4:00 PM the administrator and the DON stated the facility's expectation was for medication carts to be secured and locked when the staff were not directly using the medication cart. The DON stated the potential negative outcome could be loss of control of resident's medications. A record review of the facility's policy STORAGE OF MEDICATION dated January 2023 revealed, POLICY Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure at the time each resident is admitted , the facility must have physician orders for the resident's immediate care for 2 of 2 residents (Residents #108 and #148) reviewed for new admissions.The facility failed to ensure Resident #108 had an order in place to drain the PleurX device [a catheter inserted into the chest cavity for long-term drainage of fluid accumulation] after readmission on [DATE]. The facility admitted Resident #148 with the need for a thoracolumbar spine orthosis (TSLO) back brace and did not support the Resident with a physician's order for the TSLO brace.These failures could lead to residents not receiving necessary care. Findings included: 1. Record review of Resident #108's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included resistance to vancomycin related antibiotics, malignant pleural effusion [a fluid collection in the space surrounding the lung], and secondary malignant neoplasm of unspecified lung [lung cancer]. Record review of Resident #108's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Section I0100 indicated Resident #108 had an active diagnosis of cancer, and section OD of the MDS reflected 0 minutes of respiratory therapy treatments were administered to Resident #108 in the last 7 days. Record review of Resident #108's care plan report printed 9/22/2025 did not reflect care planning for the PleurX draining procedure. Record review of Resident #108's Order Summary Report dated 9/22/2025 reflected the following active orders: Drain pleurx drain [a catheter inserted into the chest to allow for repeated drainage of fluid] to R-front quad (R-lung) one time a day on even days for drain every other day [sic] (date ordered 9/20/2025, start date 9/22/2025) Record review of Resident #108's progress notes reflected nursing documentation indicating Resident #108 was transferred to the emergency department on 9/12/2025 at 12:00 PM for abnormal laboratory results. An additional progress note documented on 9/18/2025 at 6:44 PM reflected Resident #108 returned to the facility and that Resident #108 refused a full skin assessment and weight after arrival. Record review of a physician's progress note dated 9/19/2025 at 12:00 PM reflected the following: ASSESSMENT AND PLAN: ,,,# Lung cancer with mets to throat # squamous cell carcinoma [a type of skin cancer] # recurrent malignant right plural effusion -Plurex drain management by nursing staff, drain as ordered, and PRN, continue lasix, nebs, monitor weights -Follow up oncology and pulmonology [sic] Further record review of Resident #108's progress notes did not reveal documentation from 9/18/2025 through 9/22/2025 by nursing staff related to accessing and draining the PleurX. Record review of Resident #108's hospital discharge paperwork dated 9/17/2025 reflected the PleurX catheter had been accessed and drained by hospital staff on 9/16/2025. Record review of Resident #108's September 2025 TAR, dated 9/23/2025, reflected the following: Right pulmonary drain: drain every other day one time a day every other day for pulmonary drain/ edema drain every other day [sic] (order date 9/03/2025 2:46 AM, D/C date 9/15/2025 5:19 PM) 9/4/2025 8:00 AM: treatment performed, output documented as XmL (ADON J) 9/6/2025 8:00 AM: treatment performed, output 50mL (ADON J) 9/8/2025 8:00 AM: treatment performed, output NA (LVN F) 9/10/2025 8:00 AM: treatment performed, output 50mL (LVN F) 9/12/2025 8:00 AM: treatment performed, output 50mL (LVN F) 9/14/2025 8:00 AM: other/see nurse's notes (LVN F) Record review of Resident #108's September 2025 NMAR, dated 9/23/2025, reflected the following: 9/18/2025: no order to drain the PleurX 9/20/2025: no order to drain the PleurX Drain pleurx drain to R-front quad (R-lung) one time a day on even days for drain every other day (order start 9/22/2025) 9/22/2025 12:00 PM: drug refused In an observation and interview on 9/21/2025 at 12:34 PM, a coiled catheter was observed to Resident #108's right, lower chest area with a clean, intact dressing dated 9/16/2025. Resident #108 said the catheter had not been accessed since she returned to the facility from the hospital on 9/18/2025. She stated she had been told by multiple unknown nursing staff that they could not drain the catheter because they did not know how. She said an unknown staff member had told her yesterday (9/20/2025), that the catheter would be drained today (9/21/2025). Resident #108 said she asked the staff about the draining procedure because she was aware of the physician's order to drain the catheter every other day, and she was aware the schedule was not being followed. She said she did not feel any increase in symptoms even though the catheter had not been drained since before 9/18/2025. Resident #108 denied shortness of breath, chest pain/pressure, or difficulty breathing during the interview. In an interview on 9/23/2025 at 8:31 AM, LVN G said he was the primary nurse for Resident #108, and he was informed during change of shift report that Resident #108 had a PleurX with scheduled draining procedures occurring every five days. He said the next scheduled procedure was on 9/22/2025. LVN G was unaware the physician's order for the PleurX catheter directed nursing staff to perform the procedure every other day, and he stated he would clarify with the physician. He was unsure when the PleurX was last drained. LVN G stated he was hired at the facility approximately 1 month before and did not receive training from the facility on PleurX catheters. He said he felt comfortable accessing Resident #108's PleurX, if needed, because he had prior experience at a different facility. In an interview with ADON A on 9/23/2025 at 12:30 PM, she said she was the primary nurse for Resident #108 on 9/22/2025. She said Resident #108 informed her on 9/22/2025 that the PleurX had been drained on 9/21/2025, but ADON A did not verify this information with the medical record. She said Resident #108 then told her she would prefer to have the PleurX drained every 5 days and did not want the procedure done that day. ADON A said she had forgotten to contact the provider to discuss the request and obtain a modified order for the new frequency. In an interview with the DON on 9/24/2025 at 8:05 AM, she said she was unaware that Resident #108 did not have an order after readmission to drain the PleurX on 9/18/2025 or 9/20/2025, and she was unaware Resident #108 had been allegedly refusing the procedure. She said residents should have all orders implemented upon admission that are required to provide necessary care. 2. A record review of Resident #148's admission record dated 9/24/2025 revealed an admission date of 9/18/2025 with diagnoses which included fracture of T11-T12 vertebra without healing (the T11 and T12 vertebrae are part of the mid-back spine, which consists of 12 vertebrae labeled from T1 to T12.) further review revealed Resident ##148 was an [AGE] year-old female. A record review of Resident #148's physicians orders dated 9/24/2025 revealed no orders for a TSLO. A record review of Resident #148's care plan dated 9/23/2024 revealed no plan for interventions and or supports for a TSLO back brace. A record review of Resident #148's nursing progress notes revealed on 9/18/2025 at 4:52 PM LVN K documented, (Resident #148) admitted here from (name of hospital) hospital for nausea vomiting, AMS (altered mental status), T12-L1 fracture (fracture). Allergy to sulfa abt (antibiotic), full code, on amoxicillin abt for colitis (painful inflammation of the colon). TSLO brace when out of bed. During an observation and interview on 9/24/2025 at 10:00 AM revealed Resident #148 seated in her chair in her room, Resident #148 was observed to wear her TSLO back brace. Resident #148 stated she had a broken back, and the brace helped her with movement and minimized some of the pain. Resident #148 stated she was admitted to the facility from the hospital with the back brace. Resident #148 could not recall if she wore the brace daily but did recall a CNA applied the brace this morning. During an interview on 9/24/2025 at 10:04 AM LVN N stated her work schedule was from 6:00 AM to 6:00 PM and Resident #148 resided in the 300-hall. LVN N stated she received a report from LVN O for the 300-hall which did not include Resident #148's need for a TSLO back brace. LVN N stated she was unaware Resident #148 had a need for a back brace. LVN N performed a record review of Resident #148's medical record which included Resident #148's physicians orders, care plan, and progress notes. LVN N stated there were no orders for a TSLO brace and no care plan for a TSLO back brace. LVN N stated she reviewed Resident #148's progress notes and recognized the 1st nursing note dated 9/18/2025 which mentioned Resident #148's need for a back brace. LVN N stated she would report the discrepancies to the DON. LVN N stated the failure for an order and care plan could have a negative outcome for Resident #148 without her back brace. During an interview on 9/24/2025 at 10:11 AM CNA M stated he worked Friday 9/19/2025 through Sunday 9/21/2025 and again on 9/24/2025 from 6:00 AM to 6:00 PM and had provided care for Resident #148. LVN M stated on Saturday 9/20/2024 the therapy department staff trained him on applying Resident #148's back brace daily. CNA M stated he had not reported the training to anyone. CNA M stated he was unaware if any other CNA's were aware of Resident #148's need for a back brace and Resident #148 would be in bed after 6:00 PM and her need for the brace was when she was out of bed. During an interview on 9/24/2025 at 10:50 AM the Director of Rehabilitation (DOR) stated Resident #148 was admitted from the hospital on 9/18/2025 in the early evening. The DOR stated her staff reviewed the hospital nurse to facility nurse notes and the hospital discharge documents and recognized the hospital physician had ordered Resident #148 a TSLO brace related to her spine fracture at the T11-T12 vertebra. The DOR stated the therapy department supported Resident #148's needs for physical and occupational therapy which included the use of her TSLO brace while out of bed. The DOR stated the nursing department had access to the therapy departments notes which included the information regarding Resident #148's TSLO brace. The DOR stated she was a member of the facility's Interdisciplinary Team and had attended morning IDT meetings and recalled the review of newly admitted residents but could not directly recall Resident #148's new admission review. The DOR stated the potential negative outcome for residents who did not have orders or care plans for prosthetic devices could be a decline in health status with range of motion, pain, and or skin breakdown. During an interview on 9/24/2025 at 4:00 PM the Administrator and the DON stated Resident #148 had a need for a TSLO brace and was supported with the need for her back brace even though she had no order or care plan for the back brace. The DON stated the potential negative outcome for residents who did not have admission orders and or care plans for their admission needs could be not receiving care as prescribed by a physician. The DON stated she was responsible for the oversight for new admissions. A record review of the facility's Transcription Orders policy dated July 2025 revealed, Orders will be verified only by a Licensed Nurse or designee. If orders are transcribed by other than a licensed nurse, a licensed nurse will verify the order transcription and will sign off the orders per policy and procedure to ensure the order has been correctly transcribed and/or implemented including reviewing actions completed for scheduling or ordering medications, laboratory testing, radiology orders, referrals, diets, etc. An RN/LPN must verify the transcriptions' accuracy and completeness prior to the end of the RN/LPN's shift and PRIOR TO administration of the orders including medication administration . A record review of the facility's policy Physicians' Orders, dated May 2023, revealed, POLICY: 1. New orders and order changes may be called, hand-written, faxed, or electronically generated by a physician. 2. The physician's order must be documented completely with sufficient content to clearly convey the provider's intent. Indications for PRN orders should be included in the order. 3. After the authorized provider has completed the orders, the RN or LPN is responsible to promptly and accurately transcribe all written orders. The RN or LPN must include his/her signature, the date and time of the transcription and credentials. 4. Orders that are unclear must be clarified prior to implementation.

Based on observations, interviews, and record reviews the facility failed to develop and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the residents that met professional standards of quality care. The baseline care plan was not developed within 48 hours of a resident's admission and did not include the minimum healthcare information necessary to properly care for a resident including for 1 of 8 residents (Resident #148) [TT1] reviewed for a baseline care plan. Resident #148 was admitted on [DATE] at 5:00 PM with the need for a thoracolumbar spine orthosis (TSLO) back brace, the TSLO brace was not addressed in the baseline care plan. This failure could place residents at risk for not receiving care and services. The findings included: A record review of Resident #148's admission record dated 9/24/2025 revealed an admission date of 9/18/2025 with diagnoses which included fracture of T11-T12 vertebra without healing (the T11 and T12 vertebrae are part of the mid-back spine, which consists of 12 vertebrae labeled from T1 to T12.) further review revealed Resident ##148 was an [AGE] year-old female. A record review of Resident #148's physicians orders dated 9/24/2025 revealed no orders for a TSLO. A record review of Resident #148's care plan dated 9/23/2024 revealed no plan for interventions and or supports for a TSLO back brace. A record review of Resident #148's nursing progress notes revealed on 9/18/2025 at 4:52 PM LVN K documented, (Resident #148) admitted here from (name of hospital) hospital for nausea vomiting, AMS (altered mental status), T12-L1 fracture (fracture). Allergy to sulfa abt (antibiotic), full code, on amoxicillin abt for colitis (painful inflammation of the colon). TSLO brace when out of bed. During an observation and interview on 9/24/2025 at 10:00 AM revealed Resident #148 seated in her chair in her room, Resident #148 was observed wearing her TSLO back brace. Resident #148 stated she had a broken back, and the brace helped her with movement and minimized some of the pain. Resident #148 stated she was admitted to the facility from the hospital with the back brace. Resident #148 could not recall if she wore the brace daily but did recall a CNA applied the brace this morning. During an interview on 9/24/2025 at 10:04 AM LVN N stated her work schedule was from 6:00 AM to 6:00 PM and Resident #148 resided in the 300-hall. LVN N stated she received a report from LVN O for the 300-hall which did not include Resident #148's need for a TSLO back brace. LVN N stated she was unaware Resident #148 had a need for a back brace. LVN N performed a record review of Resident #148's medical record which included Resident #148's physicians orders, care plan, and progress notes. LVN N stated there were no orders for a TSLO brace and no care plan for a TSLO back brace. LVN N stated she reviewed Resident #148's progress notes and recognized the 1st nursing note dated 9/18/2025 which mentioned Resident #148's need for a back brace. LVN N stated she would report the discrepancies to the DON. LVN N stated the failure for an order and care plan could have a negative outcome for Resident #148 without her back brace. During an interview on 9/24/2025 at 10:11 AM CNA M stated he worked Friday 9/19/2025 through Sunday 9/21/2025 and again on 9/24/2025 from 6:00 AM to 6:00 PM and had provided care for Resident #148. LVN M stated on Saturday 9/20/2024 the therapy department staff trained him on applying Resident #148's back brace daily. CNA M stated he had not reported the training to anyone. CNA M stated he was unaware if any other CNA's were aware of Resident #148's need for a back brace and Resident #148 would be in bed after 6:00 PM and her need for the brace was when she was out of bed.During an interview on 9/24/2025 at 10:50 AM the Director of Rehabilitation (DOR) stated Resident #148 was admitted from the hospital on 9/18/2025 in the early evening. The DOR stated her staff reviewed the hospital nurse to facility nurse notes and the hospital discharge documents and recognized the hospital physician had ordered Resident #148 a TSLO brace related to her spine fracture at the T11-T12 vertebra. The DOR stated the therapy department supported Resident #148's needs for physical and occupational therapy which included the use of her TSLO brace while out of bed. The DOR stated the nursing department had access to the therapy departments notes which included the information regarding Resident #148's TSLO brace. The DOR stated she was a member of the facility's Interdisciplinary Team and had attended morning IDT meetings and recalled the review of newly admitted residents but could not directly recall Resident #148's new admission review. The DOR stated the potential negative outcome for residents who did not have orders or care plans for prosthetic devices could be a decline in health status with range of motion, pain, and or skin breakdown.uring an interview on 9/24/2025 at 4:00 PM the Administrator and the DON stated Resident #148 had a need for a TSLO brace and was supported with the need for her back brace even though she had no order or care plan for the back brace. The DON stated the potential negative outcome for residents who did not have admission orders and or care plans for their admission needs could be not receiving care as prescribed by a physician. The DON stated she was responsible for the oversight for new admissions. A record review of the facility's Care Plan policy dated April 2024, revealed, Each resident will have a care plan that is current, individualized and consistent with their medical regimen. Care Plan/MOS Coordinator, Social Services, Activities, Rehab, Dietary, Nursing and other members of the Interdisciplinary Team . POLICY: A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission, to the facility. This care plan includes minimum health care information necessarily to properly care for the resident. Therapy services

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 1 residents (Resident #87) reviewed for ADLs. The facility failed to ensure Resident #87 received routine bathing assistance after admitting to the facility in September 2025. These failures could lead to skin breakdown, infection, or psychosocial harm. Findings included: Record review of Resident #87's face sheet, dated 9/22/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included encounter for surgical aftercare following surgery on the circulatory system and dependence on renal dialysis [a procedure that filters the blood due to kidney disease]. Record review of Resident #87's MDs assessments revealed no submissions of a BIMS score assessment as of 9/21/2025. Record review of Resident #87's care plan report, printed 9/22/2025, reflected the following:resident has ADL self-care performance deficits and limitations in physical mobility (date initiated 9/16/2025)shower/bathe self: substantial maximal assistanceRecord review of the scheduled tasks in Resident #108's electronic medical record revealed Resident #108 was scheduled for bathing assistance during night shifts on Mondays, Wednesdays, and Fridays of every week. Further review revealed since admission on [DATE], staff had checked no for the bathing task on 9/16/2025 (CNA B), 9/17/2025 (CNA L), and 9/20/2025 (CNA B). 9/22/2025 was marked as not applicable by CNA L. In an observation and interview on 9/22/2025 at 9:33 AM, Resident #87's was observed resting in bed wearing a hospital gown. Resident #87 said she had not been offered assistance with bathing since her arrival at the facility. She said she had not declined a bath, and she had not thought to ask for one because her experience at previous facilities was that bathing was offered to her when someone was available to provide assistance. She denied skin issues related to not bathing. In a subsequent interview on 9/23/2025 at 12:20 PM, Resident #108 stated she was not offered assistance bathing by the previous overnight staff. In an interview with CNA D on 9/23/2025 at 12:50 PM, she stated that if residents prefer to bathe at a time that is different than the scheduled bathing time, the staff will pass the information to the incoming shift. She was not informed by the overnight staff that Resident #108 had refused bathing assistance the night prior and wanted to bathe that day. In an interview with LVN G on 9/23/2025 at 12:56, he stated he was the primary nurse for resident #108. He was unaware that Resident #108 needed assistance with bathing during the day, and he said she had not asked him for assistance that day. CNA L did not respond to a phone call and voicemail requesting interview on 9/23/2025 at 2:20 PM. CNA B was interviewed on 9/23/2025 at 2:21 PM. She said she had taken care of Resident #108 several times over the previous two weeks, and that Resident #108 consistently refused to bathe at night because she liked to shower during the day. She stated she informed the day shift staff of the need to assist Resident #108 with bathing. She was unsure of the process to change a resident's scheduled bathing time. She said she had not notified the primary nurse of Resident #108's consistent bathing refusal or that Resident #108 had not bathed since arrival. The DON was interviewed on 9/24/2025 at 8:08 AM. She stated residents are assigned bathing times based on their room number- even room numbers bathe during the day and odd room numbers bathe at night. She stated residents could request a bathing schedule change, and that staff should communicate the requests to the primary nurse or the ADON for the floor. She said that if a resident was continuously refusing bathing assistance, the staff should alert the primary nurse, and the primary nurse could escalate the situation to the ADON so that a conversation could be held with a resident's family, if able, to intervene. She was unaware that Resident #108 had not received bathing assistance since arrival. She was also unaware that Resident #108 had allegedly been refusing bathing assistance. She stated the potential harm to residents of not receiving consistent bathing assistance was skin breakdown. Record review of the facility policy titled ADL Policy revised 04/2023, revealed the following: This facility will provide each resident with care, treatment, and services according to the resident's individualized care plan . including: bathing, dressing, grooming .

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure for a resident who enters the facility with an indwelling catheter or subsequently receives one had a clinical condition that demonstrates catheterization is necessary for 1 of 3 residents (Resident # 50) reviewed for indwelling urinary catheterization necessity, in that: Resident #50 did not have a physician's order for an indwelling catheter. This deficient practice could affect residents in the facility who have an indwelling or external catheter and place them at risk for infection and improper care. The findings were: Record review of Resident #50 face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnosis that included: Urinary retention (refers to the inability to empty the bladder),Congestive heart failure (a condition where the heart muscle is weakened or stiffened), and Hypertension (is a condition where the force of blood against the artery walls is consistently too high). Record review of Resident # 50's quarterly MDS assessment dated [DATE] revealed a BIMS score 14, suggesting intact cognition, and the resdient had an indwelling catheter. Record review of Resident #50's physician's orders for September 2025, dated 09/22/2025, revealed there was no order for the resident's indwelling urinary catheter. Record review of Resident # 50's Hospital discharge orders dated 9/15/2025 revealed an order for an indwelling urinary catheter 16 fr. Observation on 09/22/25 at 10:40 a.m., revealed Resident # 50's catheter was present in the peri area, and a urinary bag was covered, hanging on the movable part of the bed frame. Interview with Resident # 50 on 09/22/2025 at 11:00 AM revealed she has had a urinary catheter since admission. Staff have always emptied the urinary bag and provided care for the appliance. Interview on 09/22/25 at 11:05 a.m. LVN H stated Resident #50 had an indwelling urinary catheter. LVN H reported that Resident #50 was admitted with an indwelling urinary catheter and verified that Resident #50 had no physician's order for the catheter. Later, she stated that she emptied the catheter each shift and checked it for signs and symptoms of infection. Interview with LVN Q ( admission nurse ) was attempted via telephone on 9/22/2025 at 11:25 am and did not return call . Interview on 9/22/25 at 3:00 p.m., the DON stated Resident #50's physician's orders did not include an indwelling urinary catheter order. The DON stated this was because the physicians' orders were entered as an order set by the admission nurse. However care was provided to the indwelling catheter by all nursing staff evident in Resident # 50's urinary bag had been emptied each shift . The DON stated Resident #50 risked possible improper care to the catheter site if the nurses did not know the resident had a urinary catheter. Record review of facility policy, Transcription of Orders, dated July 2020, revised July 2021, revealed, Transcribing and verifying orders are a responsibility of a licensed nurse .

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 2 errors resulting in a 8% medication error rate, for 2 of 8 residents (Resident #25 and Resident #126) reviewed for medication administration. 1. LVN K administered to Resident #126 his prescribed insulin aspart after breakfast contrary to the physician's orders. 2. ADON LVN A attempted to administer Resident #25 his prescribed insulin aspart after breakfast contrary to the physician's orders. These failures could place residents at risk for not receiving the therapeutic effects of their medications. The findings included: 1 A record review of Resident #126's admission record dated 9/24/2025 revealed an admission date of 9/15/2025 with diagnoses which included type II diabetes with hyperglycemia (a disease where excess sugar accumulates in the bloodstream and could contribute to infections) and infection of right knee prosthetic (artificial knee). Further review revealed Resident #126 was a [AGE] year-old male. A record review of Resident #126's care plan dated 9/24/2025 revealed, the resident is receiving insulin . blood glucose monitoring as per physician order. A record review of Resident #126's physicians orders dated 9/24/2025 revealed the physician prescribed for Resident #126 to have his blood sugar checked before meals and if needed to receive an injection of insulin according to his blood sugar level, Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML[JM2] (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2 units ; 201 - 250 = 4 units; 251 - 300 = 6 units ; 301 - 350 = 8 units ; 351 - 400 = 10 units ; 401+ = 12 units Call MD/NP for BS greater than 400, subcutaneously before meals and at bedtime for DM Notify MD/NP if over 400 or under 70. During an observation and interview on 9/23/2025 at 8:46 AM revealed Resident #126 in his bed with his bedside table across his lap. The bedside table presented with the remains of his breakfast. Resident #126 stated he had eaten breakfast about 20 minutes ago and he had not yet had his blood sugar checked. Resident #126 stated he would receive an injection of insulin if his blood sugar was high. Resident #126 stated he was supposed to have his blood sugar checked before breakfast and if needed he would receive his insulin before breakfast. During an observation and interview on 9/23/2025 at 8:48 AM revealed LVN K assessed Resident #126's blood sugar level as 155. LVN K prepared and administered 2 units of insulin aspart subcutaneously, LVN K stated she had administered Resident #126's insulin after breakfast because she did not want to administer his insulin to far ahead of his breakfast for fear he would crash regarding the insulin aspart was fast acting and would lower his blood sugar with possible negative outcomes. LVN K stated I wait to see if the meal carts were on the hall and then I administer the insulins. 2 record review of Resident #25's admission record dated 9/24/2025 revealed an admission date of 9/8/2025 with diagnoses which included diabetes type II, cerebral palsy (neurological disorders that affect movement, posture, and muscle coordination, typically caused by damage to the developing brain), and chronic kidney disease (kidney failure). Further review revealed Resident #25 was a [AGE] year-old male. A record review of Resident #25's care plan dated 9/24/2025 revealed, the resident is receiving insulin . blood glucose monitoring as per physician order. A record review of Resident #25's physicians orders dated 9/24/2025 revealed the physician prescribed for Resident #25 to have his blood sugar checked before meals and if needed to receive an injection of insulin according to his blood sugar level, Insulin Aspart Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2 units ; 201 - 250 = 4 units; 251 - 300 = 6 units ; 301 - 350 = 8 units ; 351 - 400 = 10 units ; 401+ = 12 units Call MD/NP for BS greater than 400, subcutaneously before meals and at bedtime for DM Notify MD/NP if over 400 or under 70. A record review of the American Diabetes Association's website https://diabetes.org/health-wellness/medication/insulin-routines accessed 9/30/2025, titled When to Take Insulin for Diabetes revealed, Insulin shots are most effective when you take them so that insulin goes to work when glucose from your food starts to enter your blood. For example, regular insulin works best if you take it 30 minutes before you eat. During an observation and interview on 9/23/2025 at 8:39 AM revealed ADON A prepared to administer Resident #25's insulin by first assessing his blood sugar. ADON A assessed Resident #1's blood sugar as 138. ADON A stated per the physicians' orders he would not receive an insulin injection. ADON A stated the physicians orders stated to administer the insulin prior to meals but she waited to administer Resident #25's insulin until after breakfast because she was concerned he may drop in blood sugar with potential negative outcomes. ADON A stated she would wait until the breakfast trays were out on the floor and then administer the insulin injections. ADON A stated Resident #25 was assessed with a blood sugar level of 138 after breakfast. During an observation and interview on 9/23/2025 at 8:40 AM revealed Resident #25 in his bed with his bedside table across his lap. The bedside table presented with the remains of his breakfast. Resident #25 stated he had eaten breakfast about 20 minutes ago which included sausage, eggs, toast, and oatmeal. Resident #25 stated he had just had his blood sugar checked after breakfast. During an interview on 9/24/2025 at 4:00 pm the administrator and the DON stated the expectation for insulin orders was for the nursing staff to follow physician's orders and check residents blood sugar levels before breakfast and then administer any insulins as needed before meals. The DON stated potential negative outcomes for residents could be not receiving the therapeutic effects of their medications as prescribed by their physicians. A record review of the facility's policy Medication Errors dated May 2023, revealed, POLICY: 1. An occurrence report is completed for all medication errors. 2. The DON reviews medication errors and reports them as appropriate.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 residents (Resident #108) reviewed for respiratory care. The facility failed to ensure Resident #108's long-term indwelling chest catheter, known by the brand name PleurX, was drained per physician order and by competent staff. These failures could result in infection and/or complications to a resident's respiratory or cardiovascular systems. Findings included: Record review of Resident #108's face sheet, dated 9/21/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included resistance to vancomycin related antibiotics, malignant pleural effusion [a fluid collection in the space surrounding the lung], and secondary malignant neoplasm of unspecified lung [lung cancer]. Record review of Resident #108's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating intact cognition. Section I0100 indicated Resident #108 had an active diagnosis of cancer, and section OD. of the MDS reflected 0 minutes of respiratory therapy treatments were administered to Resident #108 in the last 7 days. Record review of Resident #108's Order Summary Report dated 9/22/2025 reflected the following active orders: Drain pleurx drain [a catheter inserted into the chest to allow for repeated drainage of fluid] to R-front quad (R-lung) one time a day on even days for drain every other day [sic] (date ordered 9/20/2025, start date 9/22/2025) Record review of Resident #108's care plan report printed 9/22/2025 did not reflect care planning for the PleurX draining procedure. Record review of Resident #108's progress notes reflected nursing documentation indicating Resident #108 was transferred to the emergency department on 9/12/2025 at 12:00 PM for abnormal laboratory results. An additional progress note documented on 9/18/2025 at 6:44 PM reflected Resident #108 returned to the facility and that Resident #108 refused a full skin assessment and weight after arrival. Record review of Resident #108's scanned hospital discharge paperwork dated 9/17/2025 reflected the PleurX catheter had been accessed and drained by hospital staff on 9/16/2025. Record review of a physician's progress note dated 9/19/2025 at 12:00 PM reflected the following: ASSESSMENT AND PLAN:,,,# Lung cancer with mets to throat# squamous cell carcinoma [a type of skin cancer]# recurrent malignant right plural effusion-Plurex drain management by nursing staff, drain as ordered, and PRN, continue lasix, nebs, monitor weights-Follow up oncology and pulmonology [sic] Further record review of Resident #108's progress notes did not reveal documentation from nursing staff accessing and draining the PleurX from 9/18/2025 through 9/22/2025. Record review of Resident #108's September 2025 TAR, dated 9/23/2025, reflected the following:Right pulmonary drain: drain every other day one time a day every other day for pulmonary drain/ edema drain every other day [sic] (order date 9/03/2025 2:46 AM, D/C date 9/15/2025 5:19 PM)9/4/2025 8:00 AM: treatment performed, output documented as XmL (ADON J)9/6/2025 8:00 AM: treatment performed, output 50mL (ADON J)9/8/2025 8:00 AM: treatment performed, output NA (LVN F)9/10/2025 8:00 AM: treatment performed, output 50mL (LVN F)9/12/2025 8:00 AM: treatment performed, output 50mL (LVN F)9/14/2025 8:00 AM: other/see nurse's notes (LVN F)Record review of Resident #108's September 2025 NMAR, dated 9/23/2025, reflected the following:9/18/2025: no order to drain the PleurX9/20/2025: no order to drain the PleurXDrain pleurx drain to R-front quad (R-lung) one time a day on even days for drain every other day (order start 9/22/2025) 9/22/2025 12:00 PM: drug refusedIn an observation and interview on 9/21/2025 at 12:34 PM, a coiled catheter was observed to Resident #108's right, lower chest area with a clean, intact dressing dated 9/16/2025. Resident #108 said the catheter had not been accessed since she returned to the facility from the hospital on 9/18/2025. She stated she had been told by multiple unknown nursing staff that they could not drain the catheter because they did not know how. She said an unknown staff member had told her yesterday (9/20/2025), that the catheter would be drained today (9/21/2025). Resident #108 said she asked the staff about the draining procedure because she was aware of the physician's order to drain the catheter every other day, and she was aware the schedule was not being followed. She said she did not feel any increase in symptoms even though the catheter had not been drained since before 9/18/2025. Resident #108 denied shortness of breath, chest pain/pressure, or difficulty breathing during the interview. In an interview on 9/23/2025 at 8:31 AM, LVN G said he was the primary nurse for Resident #108, and he was informed during change of shift report that Resident #108 had a PleurX with scheduled draining procedures occurring every five days. He said the next scheduled procedure was on 9/22/2025. LVN G was unaware the physician's order for the PleurX catheter directed nursing staff to perform the procedure every other day, and he stated he would clarify with the physician. He was unsure when the PleurX was last drained. LVN G stated he was hired at the facility approximately 1 month before and did not receive training from the facility on PleurX catheters. He said he felt comfortable accessing Resident #108's PleurX, if needed, because he had prior experience at a different facility. In an interview with ADON A on 9/23/2025 at 12:30 PM, she said she was the primary nurse for Resident #108 on 9/22/2025. She said Resident #108 informed her on 9/22/2025 that the PleurX had been drained on 9/21/2025, but ADON A did not verify this information with the medical record. She said Resident #108 then told her she would prefer to have the PleurX drained every 5 days and did not want the procedure done that day. ADON A said she had forgotten to contact the provider to discuss the request and obtain a modified order for the new frequency. ADON A said she felt comfortable providing care for a PleurX catheter and that training was provided to nursing staff only as needed, but the facility did not document the training. ADON A then said there was no potential harm to Resident #108's chest tube [an alternative descriptor of the device] because the catheter was inserted into Resident #108's abdomen. ADON A clarified that a chest tube is inserted into a person's chest, but Resident #108 had a catheter in her abdomen. ADON A was unable to recall Resident #108's diagnosis that led to the need for a long-term drainage device. In an interview on 9/23/2025 at 3:23 PM, LVN F stated she had accessed and drained Resident #108's PleurX catheter several times in September. She said she had not received training from the facility for PleurX catheters, and she was shown how to perform the procedure by another nurse who was working that day. She said this was the only nurse in the building who knew how to access the PleurX. She was not aware the procedure was to be performed using sterile technique and had not utilized sterile technique on any of the procedures she performed for Resident #108. In an interview with the DON on 9/24/2025 at 8:05 AM, she said the training and skills validation for nursing staff caring for a PleurX was not included on the new hire or annual curriculum. She stated any staff who had not been trained on PleurX catheters are expected to reach out to herself or the nursing leader on call in order to receive training before accessing a PleurX. She said she had not been contacted by any staff for PleurX training since Resident #108 had admitted to the facility. She was unaware that the PleurX draining procedure was not included in Resident #108's care plan, and she felt the task should have been included. She said she was jointly responsible for the care plan with the ADONs and MDS nurse. She was unaware that Resident #108 did not have an order to drain the PleurX on 9/18/2025 or 9/20/2025, and she was unaware Resident #108 had been allegedly refusing the procedure. Record review of the facility document titled Licensed/Registered Nurse Competency Validation Checklist (undated, received 9/23/2025) did not reveal PleurX or chest tubes as a training topic. Record review of the facility policy titled Pleurx Drain Care [sic] revised 9/2024, revealed the following: All procedures must follow aseptic technique and manufacturer guidelines . Review resident's comprehensive care plan for instructions All staff must complete initial and annual competency validation .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 2 elevators reviewed for essential equipment. The facility failed to ensure elevators #1 and #2 were functioning properly. This failure could place residents at risk of not having functional and safe mode of travel from floor to floor. The findings included: Record review of Elevator #1's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of Elevator #2's Texas Department of Licensing and Regulation revealed last known annual inspection was 7/24/2024 and the hydraulic elevator passed inspection. Record review of elevator service calls documented [elevator repair company portal] from 5/21/2024 to 5/15/2025 revealed a total of 25 service calls of which 4 were related service calls: -5/15/2025 3:54 pm (after surveyor intervention) elevator 1, Jumping very hard 1 of 2 with resolution documented as checked operation pit/cylinder/packing. -4/30/2025 customer says the elevator in service but it's still bouncing and traveling extremely slow 2 of 2 with resolution documented as checked operational care in-service. -12/13/2024 elevator 2, Bouncing, still in service with resolution documented as reset. -9/26/2024 stuck 1st floor, doors closed, keep on bouncing up and down-reoccurring issue with resolution documented as checked operation. During an observation on 5/15/2025 at 3:00 pm of elevator #2, while riding from the first floor to the second floor with an unknown staff member, the elevator bounced multiple times before coming to a stop on the intended floor. The unknown staff member patted the wall and said, Good old [NAME], and indicated that was normal for the elevator. During an observation on 5/15/2025 at 3:05 p.m., elevator #2 was noted with one minimal bounce upon decent when the elevator car approached the floor. On accent the elevator car bounced 9 times when ascending from floor 1 to 3. The elevator car descended from the 2nd to 3rd car with creaking, groaning, and popping heard but no bounce. On a second run elevator #2 bounced 12 times with very noticeable movement up and down as it approached the 2nd floor from the 1st floor. No inspection was posted in this elevator. During an observation on 5/15/2025 at 3:08 p.m., elevator #1 bounced 6 times when it approached the 2nd floor from the 1st floor and 5 times from the 2nd to 3rd floor. No inspection was posted in this elevator. During an observation on 5/16/2025 at 3:35 p.m. elevator #1 and elevator #2 were utilized to observe for bouncing and noises. Elevator #2 bounced 10-11 times before coming to a rest when going up. Elevator #1 bounced 5-7 times before coming to a rest when going up. No noises were heard during this test. The elevators were taken up and down several times to observe operation. During an interview on 5/15/2025 at 3:19 p.m., the Maintenance Director stated one of the shocks for the elevators was not working and it was a known issue for an unknown period of time. He stated he could not turn elevator #2 off as it would cause the other elevator to get hot. He stated elevator 2 had the worst bounce issue. He stated approximately two-weeks prior, the elevator company had been out to service the elevators. He stated they reset the elevators with their computers, and they were waiting for parts but the reset had not fixed the issue. The Maintenance Director stated he did have the annual inspections in an office and noted the inspections were due next month. He stated he did not document service calls or repairs and did not have any invoices for repairs or parts ordered. During an interview on 5/15/2025 at 3:24 p.m., the elevator repair company declined to give a history of maintenance or service calls/repairs on the elevators for the facility. They stated they would notify the account representative who would get in contact with the facility to provide the information. During an interview on 5/16/2025 at 1:22 p.m., the Maintenance Director stated he had reviewed the ticket history of the elevators. He stated the repair company come out and adjusted both elevators with their computer on 4/23/2025. He stated the adjustment fixed the issue. He stated later he noted the elevators were doing it again. He stated he did not notice the elevators bouncing as much until yesterday (5/15/2025) when the surveyor brought it to his attention. He stated he then notified the repair company again; they came back to the facility (after surveyor intervention) and had them open up the elevators to evaluate and noted that the packing on the elevators hydraulic system needed to be replaced. The Maintenance Director stated replacing the packing on a hydraulic elevator was a lot of work. He stated he was now waiting on a bid to fix the hydraulic lines. He stated the repair company looked at the hydraulics for both elevators but only one, elevator #2 needed to be replaced. He stated the issue was the elevators worked together and when there was an issue with one elevator it affected both. He stated he could not shut off one elevator because it would cause the second elevator to overheat. He stated when they overheat, they stop working. He stated they are too hot if their oil temperature is over 160-170 F. He stated he takes the temperatures of the returns to monitor. The Maintenance Director stated they always have issues with the elevators. He stated one employee with an unknown name notified him of the elevator bounce on an unknown date. He stated he must get approval before any elevator repairs can be authorized by Corporate. The Maintenance Director stated the elevators were needed to transport residents in and out of the facility. He stated he was not aware of any resident injuries related to the elevators. During an interview on 5/16/2025 at 3:51 p.m., the DON stated both elevators had been bouncing for a couple of months now. She stated the facility had people come out and look on it (unknown date). She stated the residents did utilize the elevators. She stated the risk of the bouncing was someone could fall. She stated they had not had that happen and there were no facility injuries from the elevators. Record review of the facility's policy titled Proper maintenance on Elevators last revised August 2022 revealed: If elevator is deemed inoperable by competent person elevator will be shut down and service ticket will be open with [elevator repair company]. The policy did not address car movement or bouncing.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored properly in the cart for 1 (100 hallway med aide cart) of 2 medication carts reviewed, in that: The facility failed to ensure Resident #5's Lyrica (pregabalin), a DEA controlled substance, was stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions. The findings included: During an observation of LVN B's medication cart for the 100 hallway on 5/15/2025 at 5:00 p.m., revealed one white capsule marked Z 14 and identified as Lyrica, a schedule V (5) controlled substance, was found in an unmarked medication cup that had been removed from the locked controlled substance box of the medication cart and left in the upper right drawer of the medication cart which did not have a separate locked compartment for controlled substances. During an interview on 5/15/2025 at 5:00 p.m., CNA B stated the white capsule marked Z 14 was a capsule of Lyrica meant for Resident #5. CNA B stated she accidentally popped the medication (removed it from it's original blister pack) earlier and did not want to throw it away. She stated when that happened , she normally just left the medication in a cup to the side. She stated the medication were not labeled. She declined to answer questions on how she was trained and what she should do in this scenario. During an interview on 5/16/2025 at 4:03 p.m., the DON stated her expectation of staff were if they popped medications and were unable to give it, for whatever reason, they should waste the medication . (discard). She stated in the case of Lyrica, since it was a controlled substance, the medication should be wasted with a witness and co-signed. The DON stated controlled substances should be stored in the locked narcotic drawer to prevent drug diversion. Record review of the DEA website at https://www.dea.gov, as viewed on 5/27/2025 revealed: The Controlled Substances ACT (CSA) placed all substances which were in some manner regulated under existing federal law into one of five schedules. This placement is based upon the substance's medical use, potential for abuse, and safety or dependence liability. Schedule V drugs have the lowest potential for abuse. Pregabalin was listed as a schedule V controlled substance. Record review of thefacility's policy, titled Controlled Medication Storage dated 01/23 revealed: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations.

Based on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's medication at the correct time the medication was administered. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being. The findings included: Record review of Resident #1's face sheet, dated 5/15/2025 revealed Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses which included: displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (fracture to left leg bone with surgical repair), benign neoplasm of cerebral meninges (non-cancerous tumor of the lining of the brain and spinal cord) and generalized muscle weakness. Record review of Resident #1's 5-day admission MDS assessment dated [DATE] revealed a BIMS score of 4 which indicated a severe cognitive impairment. The assessment indicated the resident was dependent on staff for care and mobility. Record review of Resident #1's Care Plan dated 4/29/2025 revealed the resident had impaired cognitive function and staff should communicate with the resident/family/caregivers regarding resident's capabilities and needs. Record review of Resident #1's Order Summary for May 2025 revealed she had orders for: -gabapentin 100 mg, give one capsule by mouth three times a day for neuropathy. -cetirizine 10 mg, give one tablet by mouth in the morning for allergy symptoms. -metoprolol tartrate 12.5 mg by mouth two times a day for hypertension -benzonatate capsule 200 mg, give one capsule by mouth three times a day for cough. -ondansetron tablet 4 mg, give one tablet by mouth two times a day for nausea/vomiting. Record review of Resident #1's Medication Administration Audit Report dated 5/16/2025 revealed: -gabapentin 100 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m. by LVN A. -cetirizine 10 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A -metoprolol tartrate 12.5 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -benzonatate 200 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -ondansetron 4 mg was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. -polyethylene glycol 17 grams was scheduled to be administered at 7:00 a.m. on 5/01/2025 and was documented as administered at 12:25 p.m., by LVN A. During an interview on 5/16/2025 at 4:26 p.m., Resident 1's family members stated they had concerns about the times Resident #1's gabapentin was administered. The family members stated they had asked an unknown staff member when the gabapentin was administered, and the staff member gave them times that seemed too close together. They stated they had not brought their concerns about gabapentin time administration with the administration. The family stated Resident #1 was no longer at the facility. During an interview on 5/16/2025 at 3:27 p.m., LVN A stated on 5/01/2025 she administered Resident #1's medication on time during the administration window. She stated on that day, the computer kept crashing and kicking her out. She stated she was keeping track of the medication administration on a piece of paper, which she stated, she later documented in the electronic medical record. LVN A stated she did not mark the correct time of the medication administration on the medical record. She stated she did not think about changing the entry time when she documented or marking it as a late entry. LVN A stated she was trained to mark medication administration at the time it was given. During an interview on 5/16/2025 at 4:03 p.m., the DON stated her expectation of staff was to notify the ADON on the floor and to notify her (DON) if they were having issues on the floor with the computer or medication administration. She stated the staff should let the management know if a time was documented incorrectly in the medical record so it could be corrected to ensure they know exactly when medication was administered. Record review of the facility's policy titled Medication Administration Schedule undated revealed the facility utilized liberalized med pass times with morning med pass occurring between 7:00 am-10:00 am. The policy did not address documentation. Record review of the facility's policy titled Medication Administration: General Guidelines dated January 2023 revealed: Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for 14 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15) of 14 residents and involving one (LPN A) of six staff observed for confidentiality of records. The facility failed to ensure LPN A would not leave a Vital Signs Flow Sheet Report on a 200-East Hall medication cart exposing 200-East Hall residents' personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity. The findings included: During an observation on 200-East Hall on 03/13/2025 at 09:18 a.m., revealed an unattended and visible Vital Signs Floor Sheet Report, dated 03/13/2025 for shift 6A-6P (06:00 a.m. to 06:00 p.m.). The staff identified on the document was LPN A, CNA B for 06:00 a.m. to 12:00 p.m., and CNA C for 12:00 p.m. to 06:00 p.m. The document was observed facing up on an unattended, locked medication cart half-way down 200-East Hall. The document displayed 14 resident's names with their assigned room numbers (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15 residing in rooms from 201 to 215) and included information such as: blood pressures, pulses, respirations, oxygen saturations, temperatures, if continent or incontinent, and identified two residents on dialysis with their appointment time. Resident #2 and Resident #8, were listed on the report. Staff, residents, and facility guests were not observed standing or walking down the 200-East hall near the medication cart the time of observation. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication aides were responsible for taking the residents' vital signs. She stated the medication aides would give her a copy of their vital signs document and keep a second copy for their use when they enter the information into the computer. She stated the vital signs document should not be in view of everyone. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation was that no personal protected information would be visible to anyone passing by on the facility halls. She stated that personal protected information was each resident's personal information and other people should not have access to their information. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed she asked the facility staff to carry a blank sheet to put over their vitals report or to carry the report in their pocket. She revealed a vital report having been visible would be a HIPAA violation. Record review of Resident #2's Admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's progress note, titled CSC- BIMS Evaluation, dated 03/05/2025 at 11:01 a.m., reflected Resident #2 had a BIMS score of 4.0, which indicated he was severely cognitively impaired. During an interview on 03/17/2025 at 10:50 a.m., Resident #2 stated, I don't know what that is when asked how he felt about his blood pressure, pulse, and room number being visible on a document on the facility hall. Record review of Resident #8's Admission Record, dated 03/17/2025, reflected a [AGE] year-old female. She was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's Admission MDS, signed as completed on 03/10/2025 by the RN Assessment Coordinator, reflected Resident #8 had a BIMS score of 14.0, which indicated she was cognitively intact. During an interview on 03/17/2025 at 11:02 a.m., Resident #8 stated, I don't like everyone to know my information when asked how she felt about her blood pressure, pulse, and room number being visible on a document on the facility hall. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed she expected staff to keep the vitals report in binders. She revealed a vital report included patient health information that should remain confidential. Record review of facility policy, Medical Records, dated as last revised 05/2023, reflected, Purpose: To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in Federal and State laws and regulations, and to define the portion of an individual's healthcare information, whether in paper or electronic format, that comprises the medical/dental record. Under Procedure, the policy included Ensuring the privacy of protected health information (PHI) by logging out of laptops when not in use or keeping paperwork concealed and Each resident's protected health record will be filed, stored, restricted from public access .

Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care within 48 hours of a resident's admission for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission that addressed the services that were being provided for Resident #1, Resident #2, and Resident #3. This failure could place newly admitted residents at risk for not receiving the care, services, and continuity of care to meet their needs. Findings included: Record review of Resident #1's Admission Record, dated 03/13/2025, reflected a [AGE] year-old female. She was admitted to the facility on [DATE] and discharged on [DATE] to an acute care hospital. Record review of Resident #1's Medical Diagnosis EMR tab, undated and accessed on 03/12/2025, reflected Resident #1 had diagnoses which included syncope (fainting) and collapse, unspecified fall, and hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body). Record review of Resident #1's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/03/2025 at 03:13 p.m., reflected Resident #1 had severely impaired vision, was dependent on device for mobility, independent for fluid intake during meals, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity. Record review of Resident #1's Initial/Baseline Care Plan, dated and locked 03/04/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #1's Admission MDS, signed as completed on 03/12/2025 by the RN Assessment Coordinator, reflected Resident #1 had a BIMS score of 06, which indicated she was moderately cognitively impaired. She was documented as needed some help for self-care with requiring supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, partial/moderate assistance with walking 10 feet, and dependent for walking 50 feet with two turns and 150 feet. She was documented as occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #1's Care Plan, undated and accessed on 03/14/2025, reflected all care planned focuses, goals, and interventions initiated on 03/12/2025. Record review of Resident #2's Admission Record, dated 03/13/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #2's Medical Diagnosis EMR tab, undated and accessed on 03/13/2025, reflected Resident #2 had diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia (a lung infection), and schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking). Record review of Resident #2's Nurse-to-Nurse Report Sheet, dated 03/04/2025 at 09:53 p.m. by LPN F, reflected LPN F received report on Resident #2 by a hospital nurse prior to his transfer to the facility. The report included under Weight bearing Status, Resident #2 was bedbound and required two-person assist for all care needs. Incontinent of Urine and Stool were both noted to be highlighted on the report sheet. Record review of Resident #2's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 03/05/2025 at 09:50 a.m., reflected Resident #2 was bed bound, required extensive physical assistance for fluids, incontinent of bowel and bladder, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could not bear weight through at least one lower extremity and have good trunk control. Record review of Resident #2's Initial/Baseline Care Plan, dated and locked 03/05/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #2's Entry MDS, signed as completed on 03/05/2025, did not include information regarding Resident #2's self-care and mobility needs. Record review of Resident #3's Admission Record, dated 03/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #3's Medical Diagnosis EMR tab, undated and accessed on 03/17/2025, reflected Resident #3 had diagnoses which included encounter for other orthopedic aftercare (care provided after a corrective or preventative treatment on deformities, disorders, or injuries of the bones or muscles), spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), and muscle wasting and atrophy (a shrinking of muscle or nerve tissue). Record review of Resident #3's progress note, titled Nursing Evaluation (Admit,Readmit,Qtly,Annual Sig Change) [sic], dated 02/25/2025 at 05:50 p.m., reflected Resident #3 had no nutritional risks, was dependent on device for mobility, continent of bowel and bladder, had a condom catheter, could not demonstrate fine motor skill, could not safely transfer self with minimal assistance, and could bear weight through at least one lower extremity and have good trunk control. Record review of Resident #3's Initial /Baseline Care Plan, dated and locked 02/26/2025, reflected no selections for functional abilities- self-care, no selections for functional abilities- mobility, no selections for activities of daily living focuses with goals or interventions, and no selectins for mobility devices. Record review of Resident #3's Admission MDS, signed as completed on 03/03/2025 by the RN Assessment Coordinator, reflected Resident #3 had a BIMS score of 10, which indicated he was mildly cognitively impaired. He was documented as having upper extremity impairment on both sides, had used a walker and wheelchair in the last 7 days, needed supervision or touching assistance for eating and oral hygiene, substantial/maximal assistance with toileting hygiene and lower body dressing, and dependent for walking all distances. He was documented as occasionally incontinent of urine and bowel. Record review of Resident #3's Care Plan, undated and accessed on 03/14/2025, reflected the following focuses and interventions: - Focus: The resident has impaired visual function., date initiated 02/26/2025 with Intervention: Keep call light and other key items within reach., date initiated 02/26/2025. - Focus: The resident has difficulty hearing at times., date initiated 02/26/2025 with Intervention: Face guest when speaking to them., date initiated 02/26/2025. - Focus: The resident is incontinent., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - BRIEF USE: the resident uses disposable briefs. Change as needed, - Clean peri-area with each incontinence episode., - INCONTINENT: Check every 2-3 and as needed for incontinence. Wash, rinse and dry perineum (area of skin between the genitals and the anus). Change clothing PRN after incontinence episodes., and - SKIN: Provide skin care with each incontinent episode. - Focus: The resident is at risk for falls., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Anticipate and meet the resident's needs., - Ensure bed brakes are locked, and - Review information on past falls and attempt to determine cause of falls . - Focus: The resident has had an actual fall on 2/25/25 r/t Poor Balance, was assisted and witnessed by staff, date initiated 02/27/2025 with Interventions initiated on 02/27/2025 including: - Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to al requests for assistance. and - PT consult for strength and mobility. - Focus: The resident has bowel incontinence., date initiated 02/26/2025 with Interventions initiated on 02/26/2025: - Check resident every two hours and assist with toileting as needed, - Provide pericare after each incontinent episode, - Provide resident with adequate time to eliminate to minimize incontinent episodes, and - SKIN: Provide skin care with each incontinent episode. The Care Plan did not include an additional focus or interventions for ADL transfer and mobility needs. During an interview on 03/13/2025 at 05:33 p.m., RN G stated the baseline care plan was based off the initial nursing assessment with input from the dietary and therapy department. He stated the ADLs are first and must absolutely be part of the baseline care plan. He stated the initial nursing assessment was done by the direct care nurse, but they did not complete the baseline care plan. He stated he believed it was the admission nurse's duty to complete the baseline care plan. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed the direct care nurses did not complete the admissions documents for new residents. She stated the direct care nurses would receive a nurse-to-nurse document and usually a verbal report from the admissions nurse regarding new resident's ADL needs. During an interview on 03/13/2025 at 05:55 p.m., RN H stated the baseline care plan was completed by the admissions nurse. During an interview on 03/14/2025 at 01:49 p.m., CNA B revealed for new residents she would not receive a report on the new resident's ADL needs from a nurse or be provided any documentation. She stated that the nurse would receive a report, but she would typically have to ask the resident directly and learn about the resident's needs through observation. She stated if she did receive any type of report, it would come from the CNA leaving from the prior shift; however, she stated that the prior shift CNA would typically be gone or leaving at the time of her arrival for her shift, and they would not do a shift-to-shift report. During an interview on 03/14/2025 at 02:56 p.m., LPN I revealed for new residents, the direct care nurses would receive a nurse-to-nurse document and then provide a verbal report to the next nurse coming on shift. She stated oncoming nurses would also have the nursing assessment reports, which would include documentation on the resident's needs. During an interview on 03/14/2025 at 04:06 p.m., the DOR revealed the facility had therapy staff present seven days a week and new resident evaluations were generally done on the same day of admission, but always completed 24-48 hours from admission. She stated for initial communication of resident ADL needs, the nurses would receive a nurse-to-nurse report; however, once the therapy department assessed the resident, the therapy department would typically provide a verbal report to the direct care nursing staff of the resident's safe transfer needs and any restrictions. She stated the direct care staff had access to the therapy evaluations in the EMR for review. During an interview on 03/14/2025 at 04:37 p.m., LPN J revealed for new residents, she would know the resident's needs from the communication from the transferring hospital and through observing the resident. She stated some residents would be admitted with orders for feeding assistance and the nurse-to-nurse report may include a meal texture recommendation. She stated she could not recall any evaluations or documents available that showed a new resident's ADL needs, only the daily nurse notes on their observations of the resident during their shift. During an interview on 03/14/2025 at 05:11 p.m., LPN F revealed for her part of the baseline care plan, she would receive a detailed report from the transferring hospital for continuation of care and upload the nurse-to-nurse report to the new resident's chart. She stated following that step, the direct care nurse would initiate a nurse admission assessment and one of the facility RNs, typically the CNO or RN E would open a baseline care plan. She stated that once she completed the nurse-to-nurse report and the medication reconciliation and the direct-care nurse completed the head-to-toe assessment, the RN would initiate the care plan with the information from those documents and may ask clarifying questions if needed. She stated she would give a physical copy of the nurse-to-nurse report to the direct care staff. She stated that if direct care staff did not have consistent knowledge of a resident's ADL needs, it would impact the resident greatly because their care would be inconsistent. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed baseline care plans were done within 72 hours of admission. She stated that the baseline care plan needed to be initiated by herself or a facility RN. She stated that she would try to go through the baseline care plans to make sure they were as accurate as possible, including capturing any changes in the resident's care. She revealed the baseline care plan would have any information that the facility had captured for the resident, including generally having the initial therapy evaluations. She stated it might include if the resident required a Hoyer transfer, needed feeding assistance, or the resident's ability to walk. She stated the baseline care plan would include whatever information the facility knew about the resident. She stated ADL needs were communicated to direct-care staff verbally, on the nurse-to-nurse report sheet, and during CNA-to-CNA walking rounds. She stated the CNAs going off shift were supposed to do a verbal report and walking round with the CNAs coming on shift prior to leaving. She stated that if there were any changes in the resident's status or needs, the ACNO would let their staff know. She revealed that if the direct care staff's knowledge of a resident's needs were inconsistent, it could cause harm. Record review of facility policy, Care Plan, dated as last revised 04/2024, reflected, POLICY: 1. A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission, to the facility. This care plan includes minimum health care information necessary to properly care for the resident. 2. Required Components of the Baseline Care Plan a. Initial goals based on admission orders i. Services planned to attain or maintain resident's highest practical physical, mental, and psychosocial well-being including but not limited to: ADLs, Nutrition, Fall Risk, Skin Integrity and Pain Management b. Dietary Orders c. Therapy services .

Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in locked compartments for three (Cart 200-East Hall, Cart 200-West Hall, and Cart 300-West Hall) of six reviewed for drug storage. The facility failed to ensure medication carts, 200-East Hall and 200-West Hall on the second floor and 300-West Hall on the third floor were secured when unattended on 03/12/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion. Findings included: During an observation and interview on 03/12/2025 at 03:07 p.m., a medication cart on 200-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:08 p.m., RN G was observed coming out of a resident room. RN G confirmed the medication cart was his and that the cart was unlocked. He stated he had just gone to quickly administer a Tylenol to one of his residents. He stated the medication drawers that were accessible included medications such as over the counter medications, stool softeners, insulin with insulin needles, thyroid medications, and lovenox injections (a blood thinner used to prevent and treat blood clotting). RN G stated the residents on his hall required assistance with ambulation and were not independently mobile. During an observation and interview on 03/13/2025 at 03:15 p.m., a medication cart on 300-West Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 03:18 p.m., RN H was observed coming out of a resident room. RN H initially stated the medication was locked, then confirmed it was unlocked after checking. She stated her narcotics drawer was double locked and was never unsecured. She stated supplies that were accessible when the cart was unlocked included diabetic supplies, cleaning wipes, saline, oxygen supplies, prescription creams, Lidoderm patches (a numbing medication on an adhesive patch used to relieve pain), prescription medications, and breathing treatments, including albuterol (used to relax the muscles in the airway and increase air flow to the lungs). She stated she had quickly gone to one of her resident's rooms to assist him to use the restroom and empty his urinal. She stated she was only gone about two minutes. She stated all of the patients on her hall required assistance with mobility and were encouraged to use them call lights and not attempt ambulate on their own. During an observation and interview on 03/13/2025 at 05:47 p.m., a medication cart on 200-East Hall was observed to be unlocked and unattended. Facility staff and residents were not observed around the unlocked medication cart. At 05:48 p.m., LPN A identified the medication cart as hers. She stated she was checking resident blood sugar values and was only around the corner of the hall for a short time. She stated her residents required a lot of assistance and all required assistance with ambulation. She stated the medications in the cart were for the residents on the 200-East Hall but did not give detail of the medications that were accessible when the cart was unlocked. She did state that the narcotics were still locked with a separate lock. During an interview on 03/13/2025 at 05:33 p.m., RN G revealed that an unlocked cart would be a concern for patients because they could have possibly taken something from the cart. He stated the impact of this would depend on the type of medication taken. During an interview on 03/13/2025 at 05:41 p.m., LPN A revealed medication and treatment carts needed to be locked. She revealed the concern would be that anyone could have had access to the items in the cart and could walk away with them. During an interview on 03/13/2025 at 05:55 p.m., RN H revealed the concern for an unlocked medication cart was that someone could get into the cart and take something that they should not have access to and that does not belong to them. She stated that this could cause medical problems, including someone could get hurt. During an interview on 03/14/2025 at 02:19 p.m., ACNO D revealed her expectation for staff was that if they were not there and present in front of their medication carts, they were to lock it. She stated the impact of an unlocked medication cart was that someone could get into the cart and get into something that they shouldn't. That this could cause harm. She stated the impact would depend on what the person got into, the carts had injectables and medications, so the impact could range from nothing to anything. During an interview on 03/17/2025 at 10:07 a.m., ACNO E revealed her expectation was for medication carts to be always locked. She stated the impact of an unlocked medication cart was that one of the confused residents wandering around may get ahold of anything. During an interview on 03/17/2025 at 02:26 p.m., the CNO revealed her expectation was for medication carts to be always locked. She stated that the importance of securing carts was to make sure that no one goes into the cart and ingests something that they shouldn't. Record review of facility policy, 4.1 Storage of Medication, dated as copyrighted 2007 from the Nursing Care Center Pharmacy Policy & Procedure Manual, reflected, POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURES . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.