Every finding on record at Kaplan Healthcare Center

Based on observation and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 71.Findings:On 12/02/2025 at 9:00 a.m., an observation and interview was conducted with S2DON (Director of Nursing). S2DON confirmed that the nurse staffing data was posted on a whiteboard upon entry into the facility at the nurse's station. S2DON stated the nurse staffing data was from 12/01/2025. S2DON confirmed the nurse staffing data should have been updated daily and was not.

Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 71.Findings:On 12/02/2025 at 9:05 a.m., an observation and interview was conducted with S2DON (Director of Nursing). S2DON stated the survey results were pinned on the bulletin board in a packet outside of social service's office door only. S2DON confirmed the last survey results from 10/01/2025 were not in the packet and should have been posted in a place readily accessible to residents, family members, or legal representatives.

Based on interviews, observation, and record reviews, the facility failed to develop a comprehensive person-centered care plan for 3 (Resident #2, Resident #27, Resident #31) out of 35 sampled residents. Resident #27 Review of Resident #27's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with a diagnosis that included but not limited to polyosteoarthritis, neuropathy, vertebrogenic low back pain, muscle spasm of back, and cutaneous abscess of left lower limb. Further review of Resident #27's medical diagnosis did not reveal a diagnosis for left drop foot. Review of Resident #27 quarterly (Minimum Data Set) dated 10/08/2025 revealed BIMS (Brief Interview for Mental Status) of 14 which indicated Resident #27 was cognitively intact. Review of Resident #27's Medical Progress Note dated 05/14/2025 revealed a diagnosis of left foot drop.An interview was conducted on 12/01/2025 at 10:15 a.m. with Resident #27. Resident #27 stated she had left drop foot and had a brace to help her walk. An interview and record review on 12/03/2025 at 12:00 p.m. was conducted with S6MDS/LPN (Minimum Data Set/ Licensed Practical Nurse). S6MDS/LPN reviewed the EMR diagnosis list and care plan and confirmed left foot drop was not identified in the care plan. #3 Review of Resident #31's Electronic Health Records revealed an initial admission date of 01/10/2023 and a re-admission date of 11/03/2025, with diagnoses that included, but were not limited to idiopathic progressive neuropathy, benign prostatic hyperplasia with lower urinary tract symptoms, other obstructive and reflux uropathy, and retention of urine. Review of Resident #31's Minimum Data Set with an assessment reference date (ARD) of 01/10/2023 revealed in Section H that the resident had an indwelling catheter. Review of Resident #31's person centered care plan revealed no focus area and interventions to address the resident's indwelling catheter. On 12/01/2025 at 9:20 a.m., an observation was made of Resident #31. The resident had an indwelling catheter draining clear yellow urine to a urinary drainage bag hanging on his bed. On 12/02/2025 at 4:00 p.m., an interview and review of Resident #31's comprehensive person centered care plan was conducted with S4CN (Corporate Nurse). She confirmed there was no focus area and interventions to address the resident's indwelling catheter and stated that there should have been. On 12/02/2025 at 4:05 p.m., an interview and review of Resident #31's MDS and care plan was conducted with S6MDS/LPN. She confirmed there was no plan of care developed to address the resident's catheter. S6MDS/LPN stated that a care plan should have been developed to address Resident #31's indwelling catheter. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses that included sequelae of cerebral infarction and atrial fibrillation. Review of Resident #2's active physician orders as of 12/02/2025 revealed an order for Apixaban (anticoagulant/blood thinner) give 1 tablet by mouth two times a day with a start date of 04/29/2025. Review of Resident #2's MAR (medication administration record) for October and November 2025 revealed that Apixaban was administered each day. Review of Resident #2 care plan failed to reveal any focus problem, goal, or interventions related to complications or side effects of anticoagulant use. On 12/03/2025 at 11:00 a.m., an interview was conducted with S6MDS/LPN. During the interview, she reviewed Resident #2's active physician orders and confirmed the resident was receiving an anticoagulant. She then reviewed the resident's care plan and confirmed the resident was not care planned for anticoagulant use.

Based on record review and interviews, the facility failed to ensure coordination of care between the physical therapy department and nursing services for a resident who had leg prosthetic devices that no longer fit for 1 (#4) out of 35 sampled residents reviewed for quality of care.Findings:Review of Resident #4's EMR (Electronic Medical Record) revealed, in part, Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included complete traumatic amputation at level between knee and ankle, left lower leg and right lower leg, and type 2 diabetes mellitus. Review of the quarterly MDS (Minimum Data Set) dated of 10/18/2025 revealed a BIMS (Brief Interview for Mental Status) of 14 which indicated the resident was cognitively intact. Functional Abilities and Goals (GG) revealed ADL (activities of daily living) as self care deficit and lower extremity impairment on both sides.Review of Resident #4's care plan revealed bilateral (both sides) BKA (below knee amputation), with the following interventions: monitor bilateral (both sides) BKA every other day for any signs and symptoms of skin break down and Physical Therapy/ Occupational Therapy evaluation and treatment as per MD orders. The Care Plan failed to reference that Resident #4 had bilateral leg prosthetics.During an interview with Resident #4 on 12/01/2025 at 10:25 a.m., Resident #4 stated he was sent to the nursing home to heal his wounds and get prosthetics for both legs. He said his goal was to learn how to walk on his prosthetics and then return home. He stated his prosthetics are in his closet and they did not fit because he gained weight and his amputation stumps were swollen.During an interview on 12/02/2025 at 1:00 p.m. with S5SSD/LPN (Social Service Director/ Licenses Practical Nurse), she revealed had no knowledge that Resident #4 was in possession of leg prosthetics.During an interview on 12/02/2025 at 1:20p.m. with S8PTA (Physical Therapy Assistant), he stated that the physical therapy department had obtained Resident#4's leg prosthetics after his admission to the facility. He further stated that S9PO (Third Party Prosthetic Company) was scheduled to assess the resident for larger prosthetics. He reported that he was not aware that this information should have been communicated to nursing services. During an interview on 12/03/2025 at 4:00 p.m. with S4CN (Corporate Nurse) and S1ADM (Administrator), both stated that the Physical Therapy Department did not notify or communicate with any of the facility's staff that Resident #4 received leg prosthetics. They both stated the Physical Therapy Department should have collaborated with the facility regarding Resident #4 receiving bilateral leg prosthesis.

Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen, as evidenced by: 1. Equipment: A. Build-up of debris and brown substance inside the ice machine. B. Build-up of debris and food particles inside the microwave.2. Food storage: A. Walk-in Refrigerator 1. [NAME] and fuzzy patches on the inside and outside of a honey mustard container. 2. A container of lemon juice with an expiration date of 09/28/2025. B. Stand-up Refrigerator 1. A bag of bread not labeled with the date it was opened. 2. A piece of pie not labeled with the date it was prepared. C. Dry Storage 1. A bag of rice bag opened with an expiration date of 04/23/2025. This deficient practice had the potential to affect 68 residents who ate out of the kitchen.Findings:A review of the facility's policy titled, Food Receiving and Storage with a last review date of 06/23/2025, reads in part, All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).A review of the facility's policy titled, Sanitization with a last review date of 08/2025, reads in part, Fixed equipment: food contact equipment will be cleaned and sanitized after every use. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy.On 12/01/2025 at 8:29 a.m., an initial tour and interview was conducted with S3DM (Dietary Manager). She confirmed that all opened food items should have been labeled with the date it was opened and prepared and all expired items should be discarded. S3DM also confirmed that the microwave and ice machine should have been cleaned, and any food items with green and fuzzy patches should have been discarded immediately.

Based on observations, record reviews, and interviews, the facility failed to follow professional standards of practice and the comprehensive person-centered care plan to remove the AV (arteriovenous) shunt pressure dressing for 1 (Resident #28 ) out of 1 (Resident #28 ) resident reviewed for dialysis.Findings:Resident #28 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, end stage renal disease and dependence on renal dialysis.Review of Resident #28's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/21/2025 revealed in Section C that the resident had a brief interview for mental status (BIMS) score of 15, indicating the resident had normal thinking and memory.Review of Resident #28's December 2025 physician's orders revealed an order written on 12/15/2023 which read in part, dialysis M-W-F (Monday-Wednesday-Friday).Review of Resident #28's care plan revealed an intervention initiated on 04/26/2021 which read, Monitor AV shunt pressure dressing to (lt (left) arm) for excessive bleeding q (every) shift upon return from dialysis and remove dressing morning after dialysis. On 12/02/2025 at 9:20 a.m., an observation and an interview was conducted with Resident #28. The resident stated that she went to dialysis yesterday (12/01/2025). The resident pulled up the left arm sleeve of her gown revealing a white pressure dressing covering her AV shunt. The resident stated that the nurse was supposed to have checked and removed the dressing from her shunt.On 12/02/2023 at 3:00 p.m., a second observation was made of Resident #28's left arm. The resident's dressing remained covering her AV shunt. The resident stated the nurse had not removed her dressing.On 12/02/2025 at 3:05 p.m., an observation, record review, and an interview was conducted with S7LPN (Licensed Practical Nurse). She confirmed Resident #28's AV Shunt pressure dressing was not removed according to Resident #28's plan of care and stated that it should have been removed by the morning nurse on 12/02/2025.

Based on record reviews and interviews, the facility failed to maintain accurate documentation across the resident's record that the resident was discharged from hospice services for 1 (#6) out of 35 sampled residents. Findings: Review of Resident #6's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis, and cachexia. Review of Resident #6's December 2025 physician's orders revealed an order dated 09/10/2025 that read, Admit to contracted hospice provider related to CVA (cerebrovascular accident) dx (diagnosis. Further review of physician's orders revealed an order dated 09/11/2025 that read, Accucheck (blood sugar check) daily. Notify contracted hospice provider nurse if greater than 200. Review of Resident #6's October 2025 progress notes revealed a nurses note dated 10/16/2025 that read in part.resident seen by facility's medical director today post hospice D/C (discharge). On 12/03/2025 at 11:14 a.m., an interview and record review was conducted with S4CN (Corporate Nurse). S4CN confirmed Resident #6 was discharged from hospice services and the orders should have been discontinued and were not. On 12/03/2025 at 11:45 a.m., the hospice provider document titled Hospice Provider Discharge Notice was provided and revealed in part .current hospice service has/will end effective: 10/15/2025.

Based on observations, record review, and interviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This was evidenced by 1 (Resident #62) having untrimmed and unclean fingernails out of 2 Residents #61 and #62) investigated for ADLs. Findings:Review of Resident #62's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease; dementia in other diseases classified elsewhere; and unspecified osteoarthritis. Review of Resident #62's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/15/2025 revealed in Section GG that the resident required partial/moderate assistance with personal hygiene.Review of Resident #62's care plan revealed in part, the resident has an ADL self-care performance deficit, with an intervention that read: Bathing/Showering: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.On 12/03/2025 at 10:19 a.m., an observation was made of resident #62. The resident had long, untrimmed fingernails to her right hand. Underneath the resident's fingernails was a dark caked substance. On 12/03/2025 at 10:26 a.m., an observation of Resident #62's fingernails was conducted with S10CNA (Certified Nursing Assistant). She confirmed the resident's right hand fingernails were long, untrimmed, and unclean. S10CNA was asked who was responsible for cleaning and trimming the resident's fingernails. S10CNA stated that she or the shower aids cleaned and trimmed the resident's nails. On 12/03/2025 at 10:34 a.m., an observation of Resident #62's fingernails was conducted with S11LPN (Licensed Practical Nurse). She confirmed the resident's right hand fingernails were long and dirty and should not be like that. S11LPN stated that residents' nails were trimmed and cleaned on shower days.On 12/03/2025 at 10:40 a.m., a follow up interview was conducted with S10CNA. She stated that yesterday (12/02/2025) the resident stated she wasn't feeling well enough to take her shower. She stated that the resident had been showered on Sunday (11/30/2025) and Resident #62's fingernails should have been cleaned and trimmed at that time.

Based on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered diet as ordered by the physician for 1 (#21) out of 5 (#1, #21, #31, #56, #67) residents reviewed for dining.Findings: Review of Resident #21's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, non-infective gastroenteritis and colitis, dysphagia and gastro-esophageal reflux disease. Review of Resident #21's December 2025 physician's orders revealed an order dated 04/02/2025 that read, NAS (No Added Salt) diet, Chopped Meat Texture, Thin Consistency, Bite sized Meats. On 12/02/2025 at 11:41 a.m., an observation was made of Resident #21's meal tray. Resident #21's meal tray revealed a piece of rotisserie chicken leg. The meat item was not chopped or bite sized. On 12/03/2025 at 8:08 a.m., an observation was made of Resident #21's meal ticket and meal tray. Resident #21's meal ticket read in part, Chopped Meat. Meal tray revealed 2 slices of fried bacon, meat item was not chopped or bite sized. On 12/03/2025 at 8:35 a.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed that Resident #21 was on a chopped meat texture, bite sized meats diet as ordered by the physician and she confirmed the items on her meal tray were not chopped meat or bite sized.

Based on interview and record review, the facility failed to accurately code a resident's MDS (Minimum Data Set) assessment for 1 (Resident #14) out of 1 (Resident #14) investigated for resident assessments.Review of Resident #14's EHR (electronic health record) revealed she was admitted to the facility 07/14/2022 with diagnoses which included unspecified dementia, bipolar disorder, major depressive disorder and anxiety disorder.Review of Resident #14's most recent MDS (significant change) dated 09/11/2025 revealed under Section A1500 Preadmission Screening and Resident Review (PASRR) was coded as no to the question Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?Review of Resident #14's PASRR Level II Evaluation dated 09/16/2024 under the determination results section revealed Serous Mental Illness present. On 12/02/2025 2:30 p.m., an interview with S6MDS/LPN. During the interview, she reviewed Section A1500 of Resident #14's MDS dated [DATE] as well as the resident's state PASRR Level II screening and confirmed the resident's MDS was inaccurately coded.

Based on observations, interviews and record reviews, the facility failed to ensure CNAs (Certified Nurse Aides) and Shower Aides provided showers and baths for 2 (Resident #5, Resident #R1) of 2 (Resident #1, Resident #R1) sampled residents investigated for ADLs (Activities of Daily Living). Findings:On 10/1/2025, a review of the facility's policy titled, Bath, Shower/ Tub with a revision date of 2/2018 read in part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident.Resident #5Review of Resident #5's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Major Depressive Disorder, Anxiety Disorder, and Legal Blindness, as defined in the USA (United States of America). Record review of Resident #5's care plan revised on 09/11/2025 revealed a focus area which stated, ADL self-care performance deficit, and interventions which included substantial maximal assistance to shower/ bathe. Record review of Resident #5's Quarterly MDS (Minimum Data Set) dated 09/11/2025 revealed a BIMS (Brief Interview Mental Status) of 12, indicating intact cognition. During an interview with Resident #5 on 09/29/2025 at 9:30 a.m., he stated his shower days were on Mondays, Wednesdays, and Fridays in the mornings. Resident #5 stated he asked for his shower this morning when a staff member came into his room. The staff member stated to him they were short staffed then left the room. Resident #5 stated he worked out with his weights in his room. He sweats and did not like to smell musty. Resident #5 stated and would like to have a shower this morning. A follow-up interview was conducted with the Resident #5 on 09/29/2025 at 3:30 p.m. Resident #5 stated he asked another staff member after lunch for a shower, and the staff member stated they are short staffed. He stated he did not receive a shower. During the follow up interview, Resident #5's roommate, Resident #R2 stated he heard Resident #5 ask for a shower this morning and after lunch, and the employee replied that they are short staffed. Review of Resident #R2's most recent MDS assessment dated [DATE] revealed he had a BIMS score of 15, indicating his cognition was fully intact. A review of Resident #5's record did not show any evidence or documentation that the resident had received a shower on Monday 09/29/2025 during the day shift or in the morning as requested.On 09/30/2025 at 9:00 a.m., an interview with S1CNA was conducted. S1CNA stated they were sometimes short staffed. She stated when there are no shower aides on the schedule, sometimes all the showers do not get done for the day. She confirmed that if there are no shower aides then the floor aides have to do showers, as well as all other duties and the work does not always get done. On 09/30/2025 at 9:50 a.m., an interview with S7CNA was conducted. S7CNA stated Resident #5 asked to have his shower on the morning of 09/29/2025. She was unable to give him a shower because they were short staffed. S7CNA stated they are short staffed sometimes and they do the best they can to shower residents, but are not always able to shower every resident that is scheduled for a shower. S7CNA further stated they were not always able to shower residents who requested showers on their unscheduled shower days. S7CNA stated Resident #R1 asked her when he would get his shower on the morning of 09/29/2025. S7CNA stated she was also not able to shower Resident #R1 because they were short staffed.On 10/1/2025 at 1:27 p.m., an interview and review of the nursing staff schedule was conducted with S3CorpNurse and S4ADM. S4ADM confirmed that two CNA's called in and one CNA came in to work, looked at the schedule and left. S4ADM stated she was short 3 CNA's on Monday (09/29/2025). The staffing schedule for Tuesday (09/30/2025) revealed two CNA's called in. When asked if they were short staffed for CNAs on these dates, S4ADM stated no they redistributed duties to cover the shifts. S4ADM and S3CorpNurse stated when the shower aides are not available, the floor aides should provide the residents' showers. Both stated they were not aware Residents #5 and#R1 had not received their showers. S3CorpNurse stated that if a resident was scheduled for a shower on a certain day of the week, they should receive that shower on that day. If they request a shower on the day shift then they should have their shower on the day shift.Resident #R1Review of Resident #R1's electronic health record revealed an admission date of 07/05/2024. A review of Resident #R1's care plan revealed: shower/ bathe self, requires set up or clean up assistance. Review of the facility's shower schedule revealed Resident #R1's shower days were Mondays, Wednesdays, and Fridays. Further review of Resident #R1's records revealed no shower was given on 09/29/2025, and no shower given on 09/30/2025. Review of Resident #R1's Quarterly MDS 08/27/2025 revealed he had a BIMS score of 15, indicating his cognition was fully intact. On 10/01/2025 at 2:25 p.m., an interview with Resident #R1 was conducted in his room. Resident #R1 stated his shower days were on Mondays, Wednesdays, and Fridays. Resident #R1 stated that on 09/29/2025 he asked an employee if he was going to get his shower. The employee stated they were short staffed. Resident #R1 stated he did not receive his shower on Monday 09/29/2025, Tuesday 09/30/2025, nor as of 2:35 p.m. today (10/01/2025) he had not received his shower.

Based on observations, interviews, and policy and procedure reviews, the facility failed to maintain clean and sanitary kitchen equipment to prevent cross contamination and the likelihood of foodborne illnesses by failing to clean a Dumbwaiter Cart.Findings:Review of the facility's policy, Sanitization, with a last revised date of August 2025, revealed the following in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 13. Dumbwaiters may be used to transport food to dining areas and soiled dishes back to the dietary department provided that the compartment is sanitized between the transportation of soiled dishes and food. On 09/29/2025 at 12:07 p.m., an interview and observation was conducted with S14DM (Dietary Manager) of an empty dumbwaiter cart outside of the kitchen door. The cart was observed to have multiple dried clumps of yellow, brown, food matter; and dried thin layers of yellow food matter on multiple shelves. S14DM confirmed that the cart was used to deliver the lunch trays today. She stated that the cart should have been cleaned after each use. She stated based on her observations of the cart, the cart obviously was not cleaned last night nor after the last meal, and should have been.

Based on record review, observations, interviews, and policy and procedure review, the facility failed to maintain an effective 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 as evidenced by failing to:1. ensure staff wore proper PPE (Personal Protective Equipment) while providing care for 2 (#1 and #2) of 2 (#1 and #2) residents who were on Enhanced Barrier Precautions in a final sample of 6 (#1, #2, #3, #4, #5, #6) residents investigated for infection control practices; and2. ensure the shower facilities and shower equipment were cleaned and disinfected between residents for 1 (Shower room A) out of 4 shower rooms (Shower room A, Shower room B, Shower room C, Shower room D) observed.Findings:1.Review of facility policy and procedure titled, Enhanced Barrier Precautions (EBP) with a review date of 06/30/2025, read in part . Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-resistant organisms (MDROs) to staff hands and clothing. Further review of the policy indicated when EBP should be used based on the resident's status as follows: Has a chronic wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO: Use EBP- yes; Donning PPE for Residents on EBP Based on Activity Provided/Assistance While in Resident -Room: Transfer a resident- [NAME] Gloves and Gown-Yes; Changing briefs or assisting with toileting- [NAME] Gloves and Gown- Yes; Turn and Reposition or assist with bed mobility- Yes. Resident #1: Review of Resident #1 Electronic Medical Record (EMR) revealed she was admitted on [DATE] with diagnoses which included venous insufficiency, cerebral infarction, end stage renal disease, and unspecified open wound, left lower leg. A review of Resident #1's current Order Summary Report revealed a physician's order with a start date of 10/25/2024 that read; Enhanced Barrier Precautions every shift. A review of Resident #1's current Clinical Care Plan Detail revealed in part: Focus- Resident requires Enhanced Barrier Precautions r/t (related to) Wounds - Interventions/Tasks - EBP used during high-contact resident care activities as applicable, such as: Transferring, Changing briefs or assisting with toileting. On 09/30/2025 at 4:10 p.m., an observation was made outside Resident #1's room. A sign on Resident #1's door was observed stating in part: Stop- Enhance Barrier Precautions: Providers and Staff Must: Wear gloves and a gown for the following High-Contact Resident Care Activities. Transferring, Changing briefs or assisting with toileting. At this time, S1CNA (Certified Nursing Assistant) was observed entering Resident #1's room without wearing a gown. S1CNA was observed minutes later exiting the resident's room with a clear bag containing used incontinent supplies. S1CNA confirmed that she had just changed Resident #1's brief and that she wore only gloves to do this. On 09/30/2025 at 4:23 p.m., an observation was made of Resident #1 being transferred by S1CNA and S2LPN (Licensed Practical Nurse) with a mechanical lift. S1CNA was not observed wearing gloves or a gown, and S2LPN was observed without a gown on. S1CNA was then observed adjusting Resident #1's clothing after the transfer was complete. Both S1CNA and S2LPN stated that gowns did not have to be worn for care of this resident because the resident was not on EBP; the EBP sign on the door was for the resident's roommate. S1CNA stated that she did not wear gloves because she did not touch the resident. On 09/30/2025 at 4:49 p.m. an observation of the EBP sign as well as a plaque on the door frame labeled A with a picture of stop sign containing the letters EBP posted on Resident #1's door was conducted with S3CorpNurse (Corporate Nurse). S3CorpNurse stated that she was the acting Infection Preventionist for the facility. S3CorpNurse confirmed that Resident #1 was on EBP and that the plaque on the door frame with the EBP stop sign labeled A indicated which resident was on EBP. S3CorpNurse confirmed the plaque indicated that Resident #1 was on EBP. On 10/01/2025 at 1:27 p.m., an interview was conducted with S3CorpNurse and S4ADM (Administrator). S3CorpNurse confirmed that staff should have worn a gown and gloves while transferring and changing Resident #1's brief since the resident was on EBP. Resident #2: Review of Resident #2 EMR (Electronic Medical Record) revealed she was admitted on [DATE] with diagnoses which included, but not limited to peripheral pressure-induced deep tissue damage of left heel, pressure ulcer of right buttock, need for assistance with personal care, type 2 diabetes mellitus, other fecal abnormalities. The resident had an unstageable pressure ulcer on right buttock, stage IV pressure ulcer to right buttock, left heel deep tissue pressure injury, right heel deep tissue pressure injury, which required wound care. A review of Resident #2's quarterly MDS (Minimum Data Set) dated 9/20/2025, revealed a BIMS (Brief Interview Mental Status) of 15, indicating the resident's cognition was intact. A review of Resident #2's Clinical Care Plan with a review start date of 07/29/2025 and target completion date of 12/17/2025, revealed the resident required EBP (Enhanced Barrier Precautions) with a goal to reduce the potential spread of MDRO (Multidrug-resistant organism).Interventions/ Tasks: apply signage outside resident room, EBP used during high-contact resident care activities as applicable, such as: dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheter), wound care and other areas determined to require EBP. A review of Resident #2's orders revealed: EBP every shift with a start date of 04/29/2025 and active as of 10/01/2025. On 09/29/2025 at 3:48 p.m., an observation outside of Resident #2's room revealed EBP signage. On 09/29/2025 at 3:50 p.m., an observation was made of S1CNA (Certified Nursing Assistant) and S5LPN (Licensed Practical Nurse) in Resident #2's room. S1CNA was observed providing personal care to Resident #2 while the resident was in bed. S1CNA did not have a gown on. On 09/29/2025 at 3:55 p.m., an interview was conducted with S5LPN. She confirmed there was an EBP sign on the outside of Resident #2's door. She stated staff should wear gloves and a gown when providing care to the resident such as checking a brief for a bowel movement or transferring using the Hoyer lift. She confirmed that S1CNA did not have a gown on when providing care for Resident #2. On 09/29/2025 at 4:00 p.m., an observation was made of S1CNA and S11CNA transferring Resident #2 from her bed to her wheelchair with the Hoyer lift. S1CNA and S11CNA had on gloves, but were not observed wearing gowns. On 09/30/2025 at 1:30 p.m., an observation was made of S13CNA and S8CNA transferring Resident #2 from a stretcher to her wheelchair using the Hoyer lift. S13CNA and S8CNA were not observed wearing gloves or a gown. On 09/30/2025 at 1:55 p.m., an interview with S13CNA was conducted. S13CNA stated she knew Resident #2 was on EBP, and pointed to the sign on the resident's door. She stated she thought she only had to wear a gown and gloves when bathing the resident or changing her brief. She confirmed that the sign on the outside of the resident's door listed transferring as an interaction that required a gown and gloves. On 09/30/2025 at 2:00 p.m., an interview with S8CNA was conducted. S8CNA stated that she was aware that Resident #2 was on EBP. She stated that when staff transfer the resident from bed to wheelchair and wheelchair to bed, the staff should wear gowns and gloves. On 10/01/2025 at 1:27 p.m., an interview with S3CorpNurse (Corporate Nurse) was conducted. S3CorpNurse verbally confirmed that Resident #2 was on EBP. She confirmed that staff should wear gloves and a gown when transferring Resident #2 from bed to wheelchair and wheelchair to bed by Hoyer lift as well as all other care listed on the EBP sign. 2. Shower Room A A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, with a last reviewed date of 06/30/2025, read in part, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standards. Reusable items are cleaned and disinfected or sterilized between residents. On 09/30/2025 at 9:10 a.m., an observation was made in Shower Room A with S9CNA (Certified Nursing Assistant) present. S9CNA stated she had showered 4 to 5 residents this morning. The shower chair was observed with pale brown, dried, elongated drops of matter. S9CNA confirmed that she also observed the pale brown, dried, elongated drops of matter on the chair. During continued observations, dark brown, dried circular matter was observed on the wall next to the shower chair. S9CNA sprayed the cleaner/ disinfectant on the wall and shower chair, then wiped it with the washcloth. The matter easily wiped off the wall. She stated the facility's process for cleaning the shower room included that showers were to be cleaned after every resident's shower was complete and again at the end of each day. S9CNA stated she had not used that shower chair yet today, and that upon observing it, it must not have been cleaned yesterday. On 10/01/2025 at 9:25 a.m., S10CNA was observed exiting Shower Room A with a resident and returned to the shower room. Upon her return, an observation was conducted of Shower Room A with S10CNA. Upon entering, there was a strong and noticeable odor of feces. A mound of feces was observed on the shower floor inside the shower stall. S10CNA stated she had just finished a resident's shower, then she donned gloves and picked up the mound of feces off the shower floor using paper towels. S10CNA placed the feces in a clear plastic bag then discarded the bag into a trash can inside the shower room. S10CNA then proceeded to rinse the shower stall with water from the shower head. S10CNA was not observed using any cleaning products or disinfectant cleaner to clean and disinfect the shower floor or shower walls. After rinsing the shower, S10CNA opened the shower room door and assisted a resident who was waiting for a shower into the shower room. S10CNA helped the resident take off her clothes then sat the resident in the shower chair. S10CNA rolled the shower chair into the same shower stall the mound of feces was observed during the earlier part of observations. S10CNA closed the shower curtain and allowed the resident to shower. S10CNA stated that she was supposed to clean the shower with Rapid Multi Surface Disinfectant Cleanser after each resident. S10CNA stated I aint gonna lie, I don't use it after every resident. On 10/01/2025 at 10:50 a.m., an interview was conducted with S3CorpNurse (Corporate Nurse) who was the facility's Infection Preventionist and S4ADM (Administrator). S3CorpNurse stated showers should be cleaned and disinfected after each resident with the Rapid Multi Surface Spray Disinfectant. S3CorpNurse also stated that if a resident has a bowel movement on the shower floor during their shower the entire shower should be cleaned and disinfected with Rapid Multi Surfaced Spray Disinfectant.

Based on interviews, observations and record review, the facility failed to ensure the resident was provided nursing services and care that adhered to accepted standards of quality. Nursing staff failed to reconcile and administer the resident's prescribed anticoagulant medication for 39 days which jeopardized the resident's health and safety for 1 (#37) of 1 residents investigated for nursing services in a final sample of 31 residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when S3LPN (Licensed Practical Nurse) failed to resume the resident's anticoagulant Eliquis 5 mg (milligrams) twice daily after undergoing a same-day scheduled procedure at HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter. On 09/06/2024, the nurse observed Resident #37 confused and lethargic with swelling to the left lower extremity. Resident #37 was transferred via ambulance to Hospital A's emergency room (ER) for evaluation on 09/06/2024 at 3:52 p.m. Upon admit to the ER, Hospital A identified that the facility's nurses failed to administer Resident #37's Eliquis from 07/29/2024 through 09/06/2024 (a total of 39 days and 78 missed doses). Hospital A's records revealed Resident #37 was diagnosed with extensive left lower leg Deep Vein Thrombosis (DVT), placed on a Heparin drip, then transferred to Hospital B for a higher level of care and further treatment. Hospital B's records dated 09/06/2024 at 8:26 p.m., revealed in part: Eliquis failure .MRI (magnetic resonance imaging) of the resident's brain revealed a large right MCA (Middle Cerebral Artery) ischemia. Resident #37 was hospitalized until 09/12/2024 at 5:22 p.m. The facility implemented an immediate corrective action plan on 09/07/2024 which was completed prior to the State Agency's investigation. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 09/09/2024. Findings: On 11/05/2024 at 9:30 a.m., a request was made for the facility's policy regarding resident medication reconciliation. S2DON (Interim Director of Nursing/ Infection Preventionist) stated the facility did not have such policy. Review of the medical records for Resident #37 revealed the resident had a history of Atrial Fibrillation and Cerebral Infarction due to Occlusion or Stenosis of the Right Anterior Cerebral Artery. Further review revealed the resident underwent a procedure for Inferior Vena Cava (IVC) filter placement to prevent blood clots on 01/29/2024. Resident #37 was admitted to the facility on [DATE], and was prescribed Eliquis 5 mg (milligrams) twice a day since 02/24/2024. On 11/04/2024 at 1:56 p.m., a phone interview was conducted with Resident #37's responsible party (RP) who stated the resident had her IVC filter removed on 07/29/2024, and a nurse at the facility had discontinued the resident's Eliquis. The RP explained that Resident #37 was taken by ambulance on 09/06/2024. When the RP arrived at Hospital A's ER, the ER nurse who reviewed the resident's current medications identified that the resident had not received Eliquis since the IVC filter had been removed on 07/29/2024. Review of Resident #37's physician orders revealed Eliquis 5 mg tablet was held then discontinued by S3LPN on 07/25/2024. Review of the resident's medication administration record (MAR) and social services notes for July 2024 revealed Eliquis was held on 07/25/2024 to undergo a procedure at a local hospital (HC1) for IVC filter removal on 07/29/2024. Review of nursing progress notes dated 07/29/2024 at 5:30 a.m. per S6ADON (Assistant Director of Nursing) read: Resident left in stable condition via facility vehicle to HC1 for procedure. Review of the discharge orders dated 07/29/2024 from HC1 noted the resident should resume all previous medications. A listing of medication orders were attached which included Eliquis 5mg twice daily. Review of Resident #37's medication administration record (MAR) for July 2024 - September 2024 revealed the resident had not received Eliquis from 07/29/2024 - 09/06/2024. Review of nursing progress notes dated 09/06/2024 at 3:38 p.m. per S10LPNMDS (LPN Minimum Data Set Coordinator) revealed in part .at 2:40 p.m.Resident not responding to verbal stimuli .Left upper thigh swollen and warm to touch .at 2:50 p.m. S4NP (Nurse Practitioner) notified of Resident's condition and NON (New Order Noted) to send to ER for Eval (evaluation) .at 3:00 p.m. Ambulance notified of resident's condition and impending transfer .3:17 p.m. Resident left per stretcher . Review of Hospital A's medical records revealed in part, on 09/06/2024 at 3:52 p.m., Resident #37 arrived via ambulance, diverted en route to Hospital B for hypoxic episode (a period of time when the body's tissues are not getting enough oxygen). EMS (Emergency Medical Staff) reports 50% O2 (oxygen) sat (saturation), use of ambu (artificial manual breathing unit) bag. Resident arrived with 2L/NC (Liters of oxygen per Nasal Cannula) at 100%. Responsive to verbal stimuli, unable to answer questions, but does open eyes .Ultrasound of Left Lower Extremity Veins resulted on 09/06/2024 at 5:13 p.m. revealed in part, findings: Areas of mostly occlusive thrombus (blood clot) extending from the left common femoral vein through the calf. Thrombus also extends into the great saphenous vein (vein that runs from the foot to the upper thigh). The ER's note also revealed the MAR received from the nursing home did not show Eliquis was currently being given. Further review of Resident #37's medical records from Hospital A revealed on 09/06/2024 at 6:37 p.m., the ambulance called with update on transfer for higher level of care. The resident required a Heparin drip en route to Hospital B. Review of Resident #37's medical records from Hospital B revealed on 09/06/2024 at 8:26 p.m., Resident was transferred from Hospital A for DVT of LLE started on heparin drip .The resident is supposed to be on Eliquis, so this was reviewed as an Eliquis Failure Resident presented ill-appearing .significantly demented and unable to provide any meaningful history .left lower extremity with 3+ edema with mild erythema (reddening of the skin), firm to touch. Acute DVT of LLE complicated acute illness or injury with systemic systems that poses a threat to life or bodily .MRI of brain revealed a large right MCA (Middle Cerebral Artery) ischemia. Resident was hospitalized until 09/12/2024 at 5:22 p.m. and was discharged back to the nursing facility and restarted on Eliquis 5 mg twice daily. Review of the facility's Incident/Accident report by S6ADON (Assistant Director of Nursing) dated 09/09/2024 at 1:30 p.m. revealed in part: Medication Error .on 07/25, S3LPN received pre-op instructions to hold Eliquis for same procedure .Upon readmission to facility following procedure, S3LPN reviewed paperwork from hospital, read that there were no changes to medication, therefore did not reconcile and validate medications listed on hospital discharge paperwork with our eMAR (Electronic Medication Record). On 11/04/2024 at 2:00 p.m. and 3:50 p.m., attempts were made to contact S3LPN by phone, but no answer was received. On 11/04/2024 at 4:43 p.m., an interview was conducted with S2DON who verified the facility was made aware that Resident #37's anticoagulant had not been restarted since 07/29/2024 when Resident #37 was sent out to theER on [DATE]. S2DON stated a QA (Quality Assurance) report and improvement plan was started on 09/07/2024 after S1ADM and S2DON's investigation revealed Resident #37's Eliquis had been discontinued in error, and not restarted post IVC removal on 07/29/2024. On 11/05/2024 at 9:30 a.m., an attempt was made to interview Resident #37 who was laying in her bed but did not respond nor make eye contact. The resident was unable to be interviewed. On 11/05/2024 at 11:30 a.m., an interview was conducted with S1ADM who confirmed that Resident #37's Eliquis should have been restarted on 07/29/2024. She stated that S3LPN should have followed their medication reconciliation process. S1ADM stated a QA (quality assurance plan) was opened as soon as she was made aware that Resident #37's Eliquis had not been administered after the procedure on 07/29/2024. The facility implemented the following immediate corrective actions to correct the deficient practice which was completed prior to the State Agency's investigation. Review of the corrective action plan dated 09/07/2024 revealed: Admit/Re-admit Medication Reconciliation problem was identified when Resident #37 was sent to hospitalER on [DATE] and the ER nurse completed a medication reconciliation which revealed the resident had not received Eliquis since 07/29/2024. Plan of Corrective Action: 1. Immediately conducted internal review of Resident #37's electronic medical record and the discovery was made that when the resident returned from a same day procedure on 07/29/2024, S3LPN failed to restart the resident's Eliquis. 2. Monitored start-up reviewed of capturing all admit/re-admits from the hospital or with a change of medication orders with a final check completed by S11LPN. 3. Revised Care Plan conference objectives to include medications being reviewed during meetings with the resident and/or RP. 4. Implemented a change in the facility's medication reconciliation process. Any changes to any residents medications and/or readmitted will be first reconciled by the floor nurse caring for resident. Upon completion of reconciliation, nurses are to submit resident's paperwork for review to S6ADON and/or S11LPN. S6ADON will follow up the floor nurse to ensure the medication reconciliation is accurate. S11LPN to perform final review to ensure medication reconciliations are properly put in place within the MAR. 5. Resident in question MAR will be reviewed weekly to ensure her medication is administered as ordered. 6. Monitoring to begin ongoing for all new and readmit 09/09/2024 with all outcomes brought to the QAPI (Quality Assurance/Performance Improvement) committee on or before the next meeting as appropriate to ensure compliance. 09/09/2024- Nursing staff received verbal reeducation on properly reconciling a resident's medications to ensure accurate medications are being administered. On 11/04/2024 at 4:43 p.m., an interview was conducted with S2DON who explained care plan meetings were to now include medication review, monitoring of all new admit/readmits followed up for changes or new orders. S3LPN and the nursing department was re-educated on medication reconciliation on 09/09/2024. S1ADM explained when orders of any type are received, the new or discontinued orders must be reconciled with the eMAR to ensure the medications are accurate. S2DON stated she conducted the auditing of the newly admitted /readmitted residents as well as reviewed Resident #37's eMAR weekly to ensure medications were administered as ordered remotely. She stated the facility had not identified any recurring problems. On 11/05/2024 at 11:30 a.m., an interview was conducted with S1ADM who explained she conducted a verbal reeducation to S3LPN and to the other nurses on 09/09/2024. S1ADM further explained there new process was for S11LPN (Licensed Practical Nurse-Medical Records) to validate medication reconciliations are correct after admit and morning start-up meetings have been completed as a final check. On 11/04/2024 - 11/06/2024 throughout the days nursing staff interviewed were knowledgeable about the medication reconciliation process being done to ensure medications are administered accurately. S2DON's audits were reviewed and revealed all new admit/readmits residents orders were followed up to identify changes or new orders on 09/16/2024, 09/23/2024, 09/30/2024, 10/07/2024, 10/14/2024, 10/21/2024 and 10/28/2024. S2DON also completed review of Resident #37's eMAR weekly to ensure medication administered as ordered for four weeks: 09/16/2024, 09/23/2024x, 09/30/2024, 10/07/2024, 10/14/2024, 10/21/2024 and 10/28/2024. No concerns were identified with review of S2DON's audits. Twelve residents were identified as taking an anticoagulant. Review of those residents' orders and eMARs were done which revealed their anticoagulant medications were being administered as ordered for 11/01/2024- 11/04/2024; no issues were identified. Routine monitoring was conducted as appropriate with reported findings in the facility's QA/QAPI (Quality Assurance/Quality Assurance Performance Improvement) program. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 09/09/2024, thus it was determined to be a Past Noncompliance citation.

Based on interviews, observation and record review, the facility failed to ensure care and services were provided according to professional standards of practice resulting in harm for 1 (Resident #37) resident out of 31 final sampled residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when the facility's process for medication reconciliation failed as evidenced by: 1.S3LPN (Licensed Practical Nurse) failed to reconcile Resident #37's medications when the resident was readmitted to the facility following discharge from HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter on 07/29/2024. The resident's discharge orders from HC1 included administration of the anticoagulant Eliquis 5 mg (milligrams) twice daily. -S6ADON and S11LPN further failed to follow the facility's standard of practice to conduct an additional review of Resident #37's medications reconciled by S3LPN. The resident's order for Eliquis 5 mg (milligrams) twice daily had not been resumed on 07/29/2024. -S4NP (Nurse Practitioner) failed to accurately verify Resident #37's medications when rounding on the resident on two different visits on 08/19/2024 and 09/04/2024. S4NP was therefore unaware whether or not nursing staff were administering Eliquis as ordered. The facility's failed process caused Resident #37 to go without the prescribed Eliquis from 07/29/2024 through 09/06/2024 (a total of 39 days and 78 missed doses) which resulted in serious harm for Resident #37. On 09/06/2024, the resident was transferred to Hospital A where she was diagnosed with an extensive left lower leg Deep Vein Thrombosis (DVT) requiring transfer to a higher level of care to Hospital B for further treatment. Hospital B's records dated 09/06/2024 at 8:26 p.m., revealed Resident #37 was admitted for treatment due to Eliquis failure and left lower extremity DVT. MRI (magnetic resonance imaging) of the resident's brain revealed she also suffered large right MCA (Middle Cerebral Artery) ischemia. Resident #37 remained hospitalized until 09/12/2024 at 5:22 p.m. 2. Resident #37 suffered a major cognitive decline as evident by the significant decrease in her BIMS (Brief Interview for Mental Status) score. Prior to the incident, the resident was assessed as having a BIMS score of 12 indicating intact cognition, whereas after the incident the resident's BIMS score was assessed as 00 indicating severe cognitive impairment. The facility implemented an immediate corrective action plan on 09/07/2024 which was completed prior to the State Agency's investigation. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 09/09/2024. Findings: 1. On 11/05/2024 at 9:30 a.m., a request was made for the facility's policy regarding resident medication reconciliation. S2DON (Interim Director of Nursing/ Infection Preventionist) stated the facility did not have such policy. Review of the medical records for Resident #37 revealed the resident had a history of Atrial Fibrillation and Cerebral Infraction due to Occlusion or Stenosis of the Right Anterior Cerebral Artery. Review of the resident's physician orders revealed an order dated 02/24/2024 Eliquis 5 mg (milligrams) twice a day. Review of the resident's electronic health record revealed Eliquis was held on 07/25/2024 to undergo a procedure at a local hospital (HC1) for IVC filter removal on 07/29/2024. Review of the discharge orders dated 07/29/2024 from HC1 noted the resident should resume all previous medications. A listing of medication orders were attached which included Eliquis 5mg twice daily. Review of Resident #37's July 2024, August 2024 and September 2024 eMARs (electronic Medication Administration Records) revealed Eliquis 5 mg twice daily was not administered from 07/29/2024-09/06/2024 for a total of 39 days (78 doses). Review of S4NP's (Nurse Practitioner) progress notes dated 08/19/2024 and 09/04/2024 revealed no documentation addressing the resident's IVC filter removal on 07/29/2024. The medication list in S4NP's treatment plan listed Eliquis 5mg. S4NP checked off that the Medication/Treatment Regimen had been reviewed. Review of Resident #37's nursing progress notes dated 09/06/2024 at 3:38 p.m. per S10LPNMDS (LPN Minimum Data Set Coordinator) revealed in part, at 2:40 p.m. Resident #37 was not responsive to verbal stimuli; her left upper thigh swollen and warm to touch. The resident was transferred to Hospital A for evaluation at 3:17 p.m. Review of Resident #37's medical records from Hospital A revealed in part, on 09/06/2024 at 3:52 p.m., Resident #37 arrived via ambulance, diverted en route to Hospital B for hypoxic episode (a period of time when the body's tissues are not getting enough oxygen). Ultrasound of Left Lower Extremity (LLE) Veins resulted on 09/06/2024 at 5:13 p.m. revealed in part: Areas of mostly occlusive thrombus (blood clot) extending from the left common femoral vein through the calf extending into the great saphenous vein (vein that runs from the foot to the upper thigh). Review of Resident #37's medical records from Hospital B revealed on 09/06/2024 at 8:26 p.m., an Eliquis Failure. Acute DVT of LLE complicated acute illness or injury with systemic systems that poses a threat to life or bodily functions .MRI of brain revealed a large right MCA (Middle Cerebral Artery) ischemia. Resident was hospitalized until 09/12/2024 at 5:22 p.m. Review of the facility's Incident/Accident report by S6ADON (Assistant Director of Nursing) dated 09/09/2024 at 13:30 (1:30 p.m.) revealed in part: a verbal phone order had been given to S8LPNSSD to place resident's Eliquis on hold for three days, 07/27/2024 - 07/30/2024, due to a procedure. This hold order was entered into Resident #37's electronic health record (EHR) on 07/18/2024 at 9:44 a.m. by S8LPNSSD. On 07/25/2024, S3LPN (Licensed Practical Nurse) floor nurse received pre-op instructions to hold Eliquis for a same day procedure. She attempted to place the hold order in the resident's EHR but was unable to do complete it and discontinued the Eliquis on 07/25/2024 at 2215 (10:15 p.m.). Upon readmission to facility following procedure, resident's charge nurse, S3LPN, reviewed paperwork from hospital, read that there were no changes to medication, therefore did not reconcile and validate medications listed on hospital discharge paperwork with Resident #37's eMAR (electronic Medication Administration Record). On 11/04/2024 at 2:00 p.m. and 3:50 p.m., attempts were made to contact S3LPN by phone, but no answer was received. On 11/05/2024 at 9:35 a.m., a phone interview was conducted with S4NP who stated she was not made aware that the resident had the IVC filter removed on 07/29/2024 until 09/13/2024. S4NP explained she had not reviewed the resident's eMAR when she rounded on the resident on 08/19/2024 and 09/04/2024. S4NP stated she assumed the nurses were giving Resident #37's Eliquis as ordered. On 11/05/2024 at 10:16 a.m., a phone interview was conducted with S5MD (Medical Doctor/Director). S5MD stated he was not notified when the resident's IVC filter was removed on 07/29/2024. S5MD stated he was made aware that the resident's Eliquis had not been given since 07/29/2024 when the facility started their investigation on 09/13/2024. S5MD confirmed the Eliquis failure placed the resident at an increased risk of thromboembolic events. S5MD confirmed S4NP should have made sure Resident #37's medications were correct. On 11/05/2024 at 11:00 a.m., a joint interview was conducted with S1ADM and S2DON. S1ADM stated she was aware that the nursing staff made a mistake when Resident #37's Eliquis had not been resumed post IVC filter removal on 07/29/2024. S1ADM explained the prior procedure that medications were first reconciled by the floor nurse receiving the resident returning to the facility and was expected to reconcile the medications with the resident's discharge instructions and current eMAR. Then the DON or ADON reconciled the meds to ensure accuracy and resolve any discrepancies. The final person was S11LPN (Medical records) to reconcile medications. S1ADM and S2DON agreed that prior to this incident, the three person medication reconciliation process should have been done, but had not. 2. Review of the resident's Significant Change Minimum Data Set (MDS) assessment dated [DATE] with an Assessment Reference Date (ARD) of 06/28/2024 revealed the following, in part: -BIMS (Brief Interview for Mental Status) score of 12, indicating intact cognition. - Functional Limitation in Range of Motion revealed Upper Extremity (shoulder, elbow, wrist, hand) and Lower Extremity (hip, knee, ankle, foot) = 1. Impairment on one side -Set up assistance required for ADLs (Activities of Daily Living) for eating -Partial/moderate assistance required for shower/bathing, personal hygiene, and upper body dressing -Substantial/maximum assistance required for ADLs of toileting hygiene, lower body dressing and bed mobility. Review of Resident #37's medical record revealed a note from a follow up appointment with her vascular neurologist on 09/18/2024 that revealed in part . Eliquis was never resumed and patient developed a large lower extremity DVT and a right MCA territory stroke. The new MCA territory stroke has rendered her with left-sided neglect, right gaze preference, left-sided hemiplegia was present even after her first stroke. Resident's daughter believes there is a rapid decline in her clinical status after her second stroke. Resident making minimal communication and does not voice her needs at all. Review of Resident #37's Quarterly MDS assessment dated [DATE] revealed the following, in part: -BIMS score of 00, indicating severely impaired cognition. - Functional Limitation in Range of Motion revealed Upper Extremity (shoulder, elbow, wrist, hand) and Lower Extremity (hip, knee, ankle, foot) = 2. Impairment on both sides. -Substantial/maximum assistance required for eating. -Dependent on staff for all ADLs of oral/personal hygiene, toileting, shower/bathing, dressing, bed mobility and all transfers. On 11/05/2024 at 9:30 a.m., an attempt was made to interview Resident #37 who was laying in her bed. She did not respond nor make eye contact. The resident was unable to be interviewed. On 11/04/2024 at 4:05 p.m., an interview was conducted with S8LPN/SSD (Licensed Practical Nurse/Social Services Director). S8LPN/SSD stated she was familiar with Resident #37 and verified that the resident had a decline after being hospitalized [DATE] to 09/12/2024. S8LPN/SSD further stated that prior to 09/06/2024, Resident #37 was able to speak and able to feed herself, but currently the resident was unable to speak and required staff to feed her. On 11/06/2024 at 12:25 p.m., an interview was conducted with S12ST (Speech Therapist). S12ST verified that when Resident #37 was admitted to the facility at the end of February 2024, the resident was receiving therapy services and had a PEG (Percutaneous Endoscopic Gastrostomy) tube feeding. The resident was able to safely consume pleasure feedings by mouth, was communicating appropriately and stated the resident was doing very well. S12ST explained that when Resident #37 returned to the facility, after being hospitalized in September 2024, the resident had regressed greatly. The resident was unable to follow simple commands, would only nod her head sometimes. Her eating skills had regressed so much that the resident's tube feedings were increased. Plan of Corrective Action: 1. Immediately conducted internal review of Resident #37's electronic medical record and the discovery was made that when the resident returned from a same day procedure on 07/29/2024, S3LPN failed to restart the resident's Eliquis. 2. Monitored start-up reviewed of capturing all admit/re-admits from the hospital or with a change of medication orders with a final check completed by S11LPN. 3. Revised Care Plan conference objectives to include medications being reviewed during meetings with the resident and/or RP. 4. Implemented a change in the facility's medication reconciliation process. Any changes to any residents medications and/or readmitted will be first reconciled by the floor nurse caring for resident. Upon completion of reconciliation, nurses are to submit resident's paperwork for review to S6ADON and/or S11LPN. S6ADON will follow up the floor nurse to ensure the medication reconciliation is accurate. S11LPN to perform final review to ensure medication reconciliations are properly put in place within the MAR. 5. Resident in question MAR will be reviewed weekly to ensure her medication is administered as ordered. 6. Monitoring to begin ongoing for all new and readmit 09/09/2024 with all outcomes brought to the QAPI (Quality Assurance/Performance Improvement) committee on or before the next meeting as appropriate to ensure compliance. 7. S1ADM met with the contracted NP provider group to ensure the new protocol was understood. NP service will reference the actual EMAR for reconciliation of medications that residents receive. 09/09/2024- Nursing staff received verbal reeducation on properly reconciling a resident's medications to ensure accurate medications were being administered. On 11/04/2024 at 4:43 p.m., an interview was conducted with S2DON who explained care plan meetings were to now include medication review, monitoring of all new admit/readmits followed up for changes or new orders. S3LPN and the nursing department was re-educated on medication reconciliation on 09/09/2024. S1ADM explained when orders of any type are received, the new or discontinued orders must be reconciled with the eMAR to ensure the medications are accurate. S2DON stated she conducted the auditing of the newly admitted /readmitted residents as well as reviewed Resident #37's eMAR weekly to ensure medications were administered as ordered remotely. She stated the facility had not identified any recurring problems. On 11/05/2024 at 11:30 a.m., an interview was conducted with S1ADM who explained she conducted a verbal reeducation to S3LPN and to the other nurses on 09/09/2024. S1ADM further explained there new process was for S11LPN (Licensed Practical Nurse-Medical Records) to validate medication reconciliations are correct after admit and morning start-up meetings have been completed as a final check. On 11/06/2024 at 1:54 p.m., S1ADM stated the provider contacted S4NP and S13NPOwner (Nurse Practitioner Owner) of whom belong to the NP group contracted with the facility on 09/09/2024. The NP group implemented a systems change within their group's system to ensure the NPs reconcile resident medications accurately. On 11/06/2024 at 2:28 p.m., a phone interview was conducted with S13NPOwner who stated a new system was put into action by the NP group to ensure NPs accurately reconcile resident medications. The NP progress note form was revised to add wording that the medication list was to be used as reference only. NPs would now reference active orders in the resident's electronic health record and review the residents' MAR when reconciling medications for new admits/readmits or those with a significant change in condition. On 11/04/2024 - 11/06/2024 throughout the days nursing staff interviewed were knowledgeable about the medication reconciliation process being done to ensure medications are administered accurately. S4NP, S13NPOwner, and S5MD were knowledgeable about the new processes implemented by the NP group and actively involved in the facility's plan of corrective action for medication reconciliation medications.S2DON's audits were reviewed and revealed all new admit/readmits residents orders were followed up to identify changes or new orders on 09/16/2024, 09/23/2024, 09/30/2024, 10/07/2024, 10/14/2024, 10/21/2024 and 10/28/2024. S2DON also completed review of Resident #37's eMAR weekly to ensure medication administered as ordered for four weeks: 09/16/2024, 09/23/2024x, 09/30/2024, 10/07/2024, 10/14/2024, 10/21/2024 and 10/28/2024. No concerns were identified with review of S2DON's audits. Twelve residents were identified as taking an anticoagulant. Review of those residents' orders and eMARs were done which revealed their anticoagulant medications were being administered as ordered for 11/01/2024- 11/04/2024; no issues were identified. Routine monitoring was conducted as appropriate with reported findings in the facility's QA/QAPI (Quality Assurance/Quality Assurance Performance Improvement) program. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 09/09/2024, thus it was determined to be a Past Noncompliance citation.

Based on observations and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff performed hand hygiene when indicated according to accepted standards of practice during medication administration pass. Findings: On 11/05/2024, a review of the facility's policy titled Handwashing-Hand Hygiene Policy and Procedure, with a last reviewed date of 01/24/2024, revealed in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .i. After contact with a resident's intact skin .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. On 11/05/2024 at 11:06 a.m., an observation was made of S9LPN (Licensed Practical Nurse) administering insulin to a resident. After administering the medication, she returned to the medication cart and began documenting on her computer. S9LPN did not sanitize her hands before returning to her work station. On 11/05/2024 at 11:09 a.m., an interview was conducted with S9LPN. S9LPN confirmed that she had not sanitized her hands after administering insulin, and before returning to her work station. S9LPN stated that she should have sanitized her hands before returning to her work station. On 11/06/2024 at 2:19 p.m., an interview was conducted with S2DON (Registered Nurse, Interim Director of Nursing, Infection Preventionist). S2DON confirmed that staff were supposed to sanitize their hands after completing a procedure/during medication pass, and before returning to their work station.

Based on observations and interviews the facility failed to provide appropriate pharmaceutical services, by not properly disposing of a contaminated sharp, observed during medication administration. Findings: On 11/05/2024, a review of the facility's policy titled, Sharps Disposal, with a last revision date of January 2012, revealed in part: Policy Statement: This facility shall discard contaminated sharps into designated containers .1. Whoever uses contaminated sharps will discard them immediately, or as soon as feasible into designated containers . On 11/05/2024 at 11:01 a.m., an observation was made of S9LPN (Licensed Practical Nurse) perform a blood glucose test of a resident. After she performed the blood glucose test, she placed the used lancet in the palm of her gloved hand, and then removed her gloves. S9LPN returned to the medication cart, and placed her soiled gloves with the lancet inside into the trash receptacle of the medication cart. On 11/05/2024 at 11:09 a.m., an interview was conducted with S9LPN. S9LPN confirmed that she placed the used lancet inside her gloves then disposed of her soiled gloves and lancet in the trash receptacle of the medication cart. S9LPN stated she should have discarded the used lancet in the designated sharps container. On 11/06/2024 at 2:19 p.m., an interview was conducted with S2DON (Registered Nurse, Interim Director of Nursing, Infection Preventionist). S2DON confirmed that used lancets should be discarded into designated sharp containers.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) for antipsychotic use for 1 (Resident #42) out of 2 (Resident #42 and #53) residents reviewed for resident assessment discrepancy for antipsychotics. The final sample was 31 residents. Findings: Review of Resident #42's electronic revealed she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], Section N - Medications revealed the box for taking Antipsychotics was selected. Review of Resident #42's September 2024 physician orders failed to reveal an order for an antipsychotic. On 11/06/2024 at 9:50 a.m., an interview was conducted with S7RMDS (Regional Minimum Data Set). She confirmed that the resident had not received any antipsychotic medication. She stated she made an error in coding therefore the assessessment was inaccurate.

Based on record review and interviews, the facility failed to report an alleged violation of its failure to provide care to a resident necessary to avoid physical harm to designated state agency for 1 (Resident #37) out of 31 residents reviewed in the sample. On 11/04/2024 at 10:12 a.m., a request was made to the facility for all incidents that had been reported to the state agency in the past 120 days. There were no reports recieved for Resident #37. A request was also made for a policy regarding reportable incidents, but no policy was received prior to survey exit. Review of Resident #37's medical record revealed an admitted [DATE] with the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Left Femoral Vein and Paroxysmal Atrial Fibrillation. On 11/04/2024 at 1:56 p.m., a phone interview was conducted with Resident #37's Responsible Party (RP) who stated the resident had her IVC (Inferior Vena Cava) filter removed on 07/29/2024, and upon her return to the facility, a nurse discontinued the resident's Eliquis (blood thinner). Resident #37's RP explained that the resident was taken by ambulance on 09/06/2024 to Hospital A's emergency room (ER). Resident #37's RP stated when she arrived at Hospital A's ER, the ER nurse was reviewing the resident's current medications. At that time, it was identified that the resident had not been receiving Eliquis as prescribed since resident's IVC filter removal on 07/29/2024. Review of the resident's records and facility documents revealed on 07/29/2024, Resident #37 was transferred HC1 (Hospital Center) to remove her Inferior Vena Cava (IVC) filter. Resident #37 returned to the nursing home the same day as the procedure with an order to restart Eliquis 5 mg (milligrams) twice daily. S3LPN (Licensed Practical Nurse) failed to restart the resident's anticoagulant as ordered on 07/29/2024. The resident was not administered Eliquis for a total of 39 (78 doses) days from 7/29/2024 - 09/06/2024. On 09/06/2024 Resident #37's nurse noted in her notes that the appeared to be confused and lethargic, and noted with swelling to the left lower extremity. Resident #37 was sent out via ambulance to Hospital A's emergency room (ER). Upon admit to the ER, it was identified that Resident #37 had not resumed Eliquis (anticoagulant) since 07/29/2024, which resulted in an extensive left lower leg Deep Vein Thrombosis (DVT), and an extension of her previous stroke. On 11/05/2024 at 11:00 a.m., an interview was conducted with S1ADM (Administrator). She stated the facility followed the state agency's guidelines for reporting. S1ADM confirmed that Resident #37's daughter notified her in September 2024 that the resident's Eliquis was not resumed after her IVC filter was removed which subsequently caused the resident harm. S1ADM stated that she did not feel like this was a reportable incident because she completed an internal Incident/Accident Report for the medication error.

Based on record review and interviews, the facility failed to notify the physician and/or NP (Nurse Practitioner) of a resident's invasive procdure for IVC (Inferior Vena Cava) filter removal for 1 (Resident #37) out of 1 (Resident #37) residents reviewed for notification of change in a final sample of 31 residents. Review of Resident #37's medical record revealed the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, Acute Embolism and Thrombosis of Left Femoral Vein and Dysphagia following Cerebral Infarction. Review of progress note per S6ADON (Assistant Director of Nursing) on 07/29/2024 read in part: Resident left in stable condition via facility vehicle to HC1 (Hospital Center) for procedure. Review of the resident's Interventional Radiology Brief Post-procedure note revealed the date of service as 07/29/2024 at 1:54 p.m. Description of procedure: IVC filter removed without issue. On 11/05/2024 at 09:35 a.m., a phone interview was conducted with S4NP. She stated she was not made aware that Resident #37 had her IVC filter removed on 07/29/2024. S4NP explained nurses were to notify her of any change in the resident's condition and/or treatment. On 11/05/2024 at 10:16 a.m., a phone interview was conducted with S5MD. He stated was unaware the resident's IVC filter was removed on 07/29/2024. Review of the Resident #37's electronic health record failed to reveal evidence that S5MD (Medical Doctor) or S4NP were aware of the resident's IVC filter removal procedure.

Based on record review, observation and interviews, the facility failed to protect the residents' rights to be free from physical abuse by other residents for 2 (#1 and #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice resulted in 1. Physical harm for Resident #1 on 04/08/2023 at 12:30 a.m. when Resident #6 punched Resident #1 in the left eye. This resulted in Resident #1 having a swollen, black eye, and a 2.0 cm (centimeter) x 0.1 cm x 0.1 cm brow laceration. Resident #1 stated he was afraid Resident #6 would hit him again. 2. Physical harm for Resident #6 on 04/08/2023 at 12:30 a.m., when Resident #1 began hitting Resident #6 on his arms and legs. Resident #6 then punched Resident #1 in the eye which caused Resident #6 right hand pain, redness, swelling, and abrasions to the 3rd knuckle and between the 4th and 5th knuckle. Resident #1 then pulled Resident #6's hair (so Resident #6 could not punch him again) and would not let go until facility staff intervened. Findings: Review of the facility's policy, Abuse Prohibition Policy revealed, in part, the following: Intent: Each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse . Policy: The facility will prohibit neglect, mental or physical abuse . Definitions: Abuse means the willful infliction of injury . punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, hitting, slapping, kicking, shoving, pinching . Examples of verbal/mental abuse include . things to frighten a resident. Resident #1 Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Major Depressive Disorder Recurrent Severe With Psychotic Symptoms, Acquired Absence Of Right Leg Above Knee and Muscle Weakness (Generalized). Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating his cognition was moderately impaired. Review of Resident #1's comprehensive care plan, dated 04/08/2023, revealed, in part, resident is/has potential to be physically aggressive related to anger, physical aggression received with an intervention on 04/08/2023 resident had a physical altercation with roommate. Review of the facility's Incident Log for the past 120 days revealed one incident of Physical Aggression Received for Resident # 1, dated 04/08/2023 at 12:30 a.m. Review of the facility's Incident Report dated 04/08/2023 at 12:30 a.m., revealed, in part, the following: Incident Type: Physical Report Prepared By: S2LPN (Licensed Practical Nurse) Nursing Description: Upon arriving to resident's room, Resident #1 has Resident #6's hair curled in his hand refusing to let go. Resident #1 states he was not going to release Resident #6 because Resident #1 was scared he would hit him again. Resident Description: Resident #1 stated he went over to Resident #6's side of the room to ask him to turn the volume down on the television. Resident #1 stated Resident #6 hit him first in the face then he started to hit Resident #6 but does not recall where he was hitting him. Injury Type: Sharp Puncture/Laceration Injury Location: Face Action Taken Description: Cleaned lacerations and applied steri strips above left eye. Review of S2LPN handwritten statement read in part . On 04/08/2023 I was at unit two med cart when I summoned to room by S3LPN. Upon arrival to room Resident #1 was in his wheelchair grabbing Resident #6's hair pulling his head down. Both parties were facing the entry way sitting in their wheelchairs .Resident #1 has swollen, blacken left eye and deep laceration above left eye. Resident #6 has multiple minor lacerations to right hand/knuckle. Review of S3LPN handwritten statement read in part . On 04/08/2023 I could hear a banging and I followed the noise and once I opened the door Resident #1 and Resident #6 were holding each other by hands and hair . Resident #1 had Resident #6 by the hair and Resident #6 was holding both of Resident #1's hands. I asked what is going on and Resident #6 replied he attacked me . Resident #6 says I came out the bathroom and was going to bed and he came to my side and hit me then I started to hit him back in his face . Review of Resident #1's weekly wound assessment, dated 04/11/2023, revealed, in part, the following: Wound Description: Skin tear to left brow area, steri strip in place. Wound was acquired on 04/08/2023 with measurement taken in cm and measured by length x width x depth of 2.0 cm x 0.1 cm x 0.1 cm Review of Resident #1's current physician's orders revealed an order on 04/08/2023 monitor steri-strips above left eye for seven days or until resolved. Review of Resident #1's Nurses Notes revealed, in part, the following: 04/08/2023 at 8:30 a.m. written by S1DON (Director of Nursing) Attempted to interview Resident #1 about reported altercation with roommate during the night. Resident #1 repeatedly mumbled, No when asked. Resident is noted with small cut to left brow area with steri strips x 2 intact and discoloration to left eye. 04/10/2023 at 10:18 a.m. written by S1DON Late entry from nurse note S2LPN for 04/08/2023. This nurse was at unit 2 med cart when summoned to resident's room by S3LPN. Upon arriving to resident's room, Resident #1 was sitting in his wheelchair back facing the bathroom. Resident #1 had Resident #6's hair curled in his hand refusing to let go. Resident #1 states he was not going to release Resident #6 because he was scared he would hit him again. On 04/10/2023 at 10:55 a.m., an interview and observation was conducted with Resident #1. Resident #1's speech was incomprehensible. Resident #1 was asked about the incident that occurred between him and his roommate. Resident #1 responded by moving his hand in the form of a fist and then pointed to his left eye. Resident #1's left eye was observed to have a laceration near his left eyebrow with steri strips in place and his left eye was discolored. Resident #6 Review of Resident #6's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Major Depressive Disorder, Other Specified Anxiety Disorders, Spinal Stenosis and Insomnia. Review of Resident #6's most recent Quarterly MDS assessment, dated 02/16/2023, revealed the resident had a BIMS score of 15 indicating his cognition was cognitively intact. Review of Resident #6's comprehensive care plan, dated 04/08/2023, revealed, in part, resident is/has potential to be physically aggressive with an intervention on 04/08/2023 resident had a physical altercation with roommate. Review of Resident #6's Nurses Notes revealed, in part, the following: 04/08/2023 at 9:33 a.m., written by S1DON. Interviewed resident about altercation with roommate last night. Resident #6 states I was coming out of the restroom in my wheelchair when I was returning to bed on the other side of the room when Resident #1 started hitting me on my arms and legs and pulling my hair. Resident #6 then hit him on the head with right hand to make him stop. 04/08/2023 at 11:10 a.m. written by S1DON Resident #6 complains of right hand pain. Noted redness and slight edema. Band aid intact to skin break on right hand on third knuckle and between fourth and fifth knuckle. Resident #6 stated it might be broken from when Resident #6 hit Resident #1 last night when Resident #1 was hitting on me and pulling my hair. On 04/10/2023 at 10:22 a.m. written by S1DON Late Entry from S2LPN from 04/08/2023. This nurse was at unit two med cart when summoned to Resident #6's room by S3LPN. Upon arriving to resident's room, Resident #6 was in his wheelchair facing the entry to the room right outside the bathroom door. Resident #1 had Resident #6 by the hair pulling his head down. Resident #6 had his hands on Resident #1's hands trying to make his let go. On 04/10/2023 at 11:10 a.m., an interview and observation was conducted with Resident #6. Resident #6 reported he was going back to his bed after using the restroom and bumped into Resident #1's wheelchair. Resident #1 then went to Resident #6's side of the room and started hitting him. Resident #6 stated he then punched Resident #1. Resident #6 stated Resident #1 then grabbed his hair. Resident #6's right hand was observed to have an abrasion to third knuckle and between fourth and fifth knuckle. On 04/10/2023 at 11:22 a.m., an interview was conducted with S1DON. She reported that she received a call on 04/08/2023 at around 12:30 a.m. from S2LPN about an altercation between two residents. She stated that she was told by S2LPN that Resident #6 was getting out of bathroom and Resident #1 approached him and grabbed Resident #6's hair, and then Resident #6 punched Resident #1. She confirmed this was an incident of resident to resident abuse. On 04/11/2023 at 7:00 p.m., an interview was conducted with S3LPN. She reported on 04/08/2023 she was making rounds when she got to Resident #1 and Resident #6's room she heard a banging noise. S3LPN reported that Resident #1 and Resident #6 were holding each other back. S3LPN reported Resident #1 had a laceration above his left eye and bruising was starting to form around his left eye, Resident #6 had scratches on his right hand near the knuckle. She confirmed this was an incident of abuse. Three attempts were made to contact S2LPN via phone on 04/11/2023 at 9:30 a.m., at 10:30 a.m., and at 11:00 a.m. S2LPN failed to return any phone calls and was unable to be interviewed.