Every finding on record at Kirkwood Manor

Based on observation, interviews, and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (1) of five (5) residents (Residents #1) reviewed for accurate medical records. The facility failed to ensure nursing staff documented the exceptions to the venous stasis prevention (preventing the congestion and slowing of circulation in the veins due to blockage) and wound care prevention orders for Resident #1. These failures could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay.The findings included: Record review of Resident #1's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed 06/16/2026 at 04:21 p.m., reflected diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (a disruption in the brain's blood flow) affecting left non-dominant side, hyperlipidemia (high fat levels in the blood), and chronic peripheral venous insufficiency (a long-lasting condition in which the veins have problems sending blood from the legs back to the heart). Record review of Resident #1's Quarterly MDS Assessment, dated 05/20/2026, reflected the resident had a BIMS score of 15, which indicated he was cognitively intact. He had a limited range of motion on one side of a lower extremity (an inability to fully move a hip, knee, ankle, or foot) and normally used a wheelchair. He required substantial/maximal (more than half) assistance with walking, moving from sitting to standing, and moving from chair/bed-to chair. He was noted to be at risk of developing pressure ulcers/injuries and was documented to not have any present skin ulcers, wounds, or skin problems. Record review of Resident #1's Order Audit Report, dated 06/16/2026, reflected the following order summary with order status, order date, start date, order signed by, and the strike out date if available: - APPLY LONG TERM WRAPS TO BILATERAL LEGS [both legs] DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention [preventing the congestion and slowing of circulation in the veins due to blockage] therapy applies wraps while on services, order noted as active, order dated 09/17/2025, order signed by MD A on 09/23/2025, and a strike out date was not entered. Record review of Resident #1's Order Audit Report, dated 06/16/2026, reflected the following order summary with order status, order date, start date, order signed by, and the strike out date if available: - REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, order noted as active, order dated 08/25/2025, order signed by NP B on 08/29/2025, and a strike out date was not entered. Record review of Resident #1's Medication Administration Record, printed 06/16/2026 and dated 06/01/2026 - 06/30/2026, reflected the orders:- APPLY LONG TERM WRAPS TO BILATERAL LEGS DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention therapy applies wraps while on services, order date 09/17/2025. The order was documented as administered from 06/01/2026 to 06/16/2026. LPN C was noted to have documented as administered the order on 06/06/2026, 06/07/2026, 06/13/2026, and 06/14/2026. - REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, order date 08/25/2025. The order was documented as administered from 06/01/2026 to 06/15/2026. LPN C was noted to have documented as administered the order on 06/06/2026, 06/07/2026, 06/13/2026, and 06/14/2026. Record review of Resident #1's Care Plan Report, undated and accessed 06/16/2026 at 4:48 p.m., reflected the following focus and interventions/tasks: - Focus: Has actual impairment to left anterior [left front] shin skin integrity r/t Edema [swelling caused by excess fluid trapped in the body's issues], date initiated 10/03/2024 and revised 01/09/2026. - Intervention/Task: APPLY LONG TERM WRAPS TO BILATERAL LEGS DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention therapy applies wraps while on services, date initiated 01/09/2026. - Intervention/Task: REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, date initiated 01/09/2026. During an observation and interview on 06/17/2026 at 11:35 a.m., Resident #1 was observed in his room, lying in bed, with bed sheets covering his lower body. His leg wraps were not visible. Resident #1 stated his legs were wrapped. He did not clarify what type of wraps were on his legs. He stated sometimes the staff do not wrap his legs; it depended on what the therapist wanted. He stated he slept with his legs wrapped and they changed the wraps every day or every other day. He stated he did not have pain in his legs, resulting from lipedema (fat in his blood), because they wrapped his legs. During an interview on 06/17/2026 at 01:08 p.m., the Therapy Program Manager stated Resident #1 was receiving therapy Monday to Friday and on therapy days, therapy staff were putting on compression wraps. She stated the therapists coordinated with the wound care nurse to determine when the wraps order was completed by the nursing staff or therapy staff. She stated it depended on where Resident #1 was in the lipedema treatment protocol (the type and degree of treatment would be customized to address the stage of symptoms) to determine if he would need to keep the compression wraps on during the night or not. She stated, typically the wraps were administered in the morning and then removed in the afternoon, and sometimes an additional type of wrap or specialized compression garment would be administered. She stated Resident #1 currently has his compression wraps put on in the morning and taken off in the afternoon because per his measurements, the measurement around his legs, Resident #1 was making good progress. She stated Resident #1 had a history of refusing treatment but had an improved chance of agreeing to treatment if PT D administered the wraps. She stated, if Resident #1 refused a therapy treatment during the week, he would most likely be encouraged to make up the treatment over the weekend, but he was not scheduled regularly for treatment over the weekend. She stated she would have to confirm with PT D to determine if therapy was exclusively administering Resident #1's wraps; however, most of the time the therapy staff administer them because they are more skilled in the lipedema protocols. She stated the nurses might have to mark the order as completed after confirming the treatment was applied by the therapists. She stated, right now the order stated therapy applied the wraps while Resident #1 was on service, but the administration of the order was more of a fluid thing, meaning it would depend on where the resident was in the treatment process. During an interview on 06/17/2026 at 01:50 p.m., PT D stated Resident #1 was receiving therapy Monday to Friday, five (5) days a week. He stated Resident #1 was only seen by therapy on weekends if Resident #1 missed a day during the week. He stated Resident #1 was very particular and would frequently refuse if he or another therapist were not available to provide Resident #1's treatment. PT D stated therapy applied Resident #1's wraps Monday to Friday and on Friday before the end of day, he would apply compression stockings for Resident #1 to wear over the weekend. PT D stated Resident #1 had the compression stockings taken off over last weekend, 06/13/2026- 06/14/2026, which resulted in Resident #1's legs having been really swollen by Monday. PT D stated if Resident #1 had a single wrapping on, then the weekend nurse would apply an additional Velcro wrap during the day, if Resident #1 allowed them. He stated Resident #1's nurse and he would communicate about what type of wraps were applied in therapy so the nurse would know if the wraps had been changed or not. During an interview on 06/17/2026 at 02:23 p.m., ADON E stated she understood that during the week Resident #1's wraps were administered by therapy staff and then nursing staff would remove them. She stated when Resident #1 asked for the wraps to be removed, the staff would have to comply with his request. She stated LPN C was very consistent with Resident #1's treatment during the weekend and was aware Resident #1 would frequently ask for the wraps to be taken off. During an interview on 06/17/2026 at 03:02 p.m., LPN C stated for Resident #1's wraps, they would sometimes be left on overnight or over the weekend, but Resident #1 would frequently request for the wraps to be removed. She stated the nurses would sometimes apply the Velcro wraps, but Resident #1 would frequently ask for them removed. She stated most of the time, if she saw Resident #1 had wraps applied by therapy, she would not change, add, or remove them unless he requested for them to be removed. She stated for Resident #1's wrap orders, they do not always match the current treatment procedure. She stated she would just check off the order as administered if the wraps were done by therapy. She stated she would not document if the resident requested the wraps or treatment to be removed early or if the wrap type was different than the order. She stated she read Resident #1's order as referring to the Velcro wrap the nursing staff applied, not the compression wrapping the therapist applied, which were different. During an interview on 06/17/2026 at 04:18 p.m., the DON stated Resident #1's wraps were usually provided by therapy during the week, and the therapist would coordinate with Resident #1's nurse, per the nurses' scope (area of practice the nurse is deemed competent). For the weekends, therapy was available, but PT D would coordinate with the nursing staff. He stated the nurses that provided Resident #1's care were consistent, so they were familiar with his current care. He stated the nursing staff performed visual assessments of the wraps to confirm they were present when marking the Medication Administration Record for the order as completed. He stated the nurse was validating the order was complete. During an interview on 06/17/2026 at 04:55 p.m., the ADOR stated she and PT D had certifications to provide lipedema treatment. She stated the long-term wraps that were noted in Resident #1's order were for maintenance of the lipedema, to try to prevent the regression in Resident #1's leg circumference measurement, and they could be applied by the nursing staff. She stated the two-layer wraps could only be applied by a certified therapist or an assistant therapist trained in lipedema management. The ADOR stated, for Resident #1, the two-layer wraps could stay on Resident #1's legs for up to 72 hours, but it would depend on Resident #1's tolerance for the wraps. She stated if Resident #1 was seen by therapy, PT D might apply the two-layer wraps, depending on the treatment approach PT D determined to be appropriate that day. If Resident #1 was wrapped with the two-layer wraps, then the long-term wraps would not be applied on top of the two-layer wraps. She stated she was not sure what options the nurses had in documentation of the order administration, but if Resident #1 was refusing or asking for all the wraps removed, then the order was refused. She stated the long-term wraps were essentially not applicable when the two-layer wraps were applied by therapy. She stated she could see that there could be a potential misunderstanding of what qualifies for the ordered wrap, such as checking off with what therapy administered versus the treatment noted in the order. She stated the nursing staff were given instruction that if Resident #1 received the two-layer wraps and had them on, then the long-term wraps would not be applied. She stated the nursing staff were not necessarily removing Resident #1's wraps each evening but if the ordered long-term wraps were applied, they were to be removed during the evening shift. Attempted interview on 06/17/2026 at 05:50 p.m. with MD A. NP B had the same office contact information as MD A. Office messaging system stated the office was closed for the day. During an interview on 06/17/2026 at 05:51 p.m., the ADOR stated the facility did not have a rehabilitation services policy or a lipedema policy. Record review of the facility's policy, Section Administration and Subject Documentation and Charting, dated revised 05/2007 and last reviewed 07/2022, reflected: Policy:It is the policy of this facility to provide:1. A complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care.2. Guidance to the physician in prescribing appropriate medications and treatments.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and physician's orders for one (1) of five (5) residents (Resident #1) reviewed for quality of care. The facility failed to complete Resident #1's venous stasis prevention (preventing the congestion and slowing of circulation in the veins due to blockage) and wound care prevention per physician orders. These failures could place residents at risk of not receiving necessary medical care, harm, and hospitalization.The findings included: Record review of Resident #1's Face Sheet, dated 06/16/2026, reflected a [AGE] year-old male. He was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed 06/16/2026 at 04:21 p.m., reflected diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (a disruption in the brain's blood flow) affecting left non-dominant side, hyperlipidemia (high fat levels in the blood), and chronic peripheral venous insufficiency (a long-lasting condition in which the veins have problems sending blood from the legs back to the heart). Record review of Resident #1's Quarterly MDS Assessment, dated 05/20/2026, reflected the resident had a BIMS score of 15, which indicated he was cognitively intact. He had a limited range of motion on one side of a lower extremity (an inability to fully move a hip, knee, ankle, or foot) and normally used a wheelchair. He required substantial/maximal (more than half) assistance with walking, moving from sitting to standing, and moving from chair/bed-to chair. He was noted to be at risk of developing pressure ulcers/injuries and was documented to not have any present skin ulcers, wounds, or skin problems. Record review of Resident #1's Order Audit Report, dated 06/16/2026, reflected the following order summary with order status, order date, start date, order signed by, and the strike out date if available: - APPLY LONG TERM WRAPS TO BILATERAL LEGS [both legs] DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention [preventing the congestion and slowing of circulation in the veins due to blockage] therapy applies wraps while on services, order noted as active, order dated 09/17/2025, order signed by MD A on 09/23/2025, and a strike out date was not entered. Record review of Resident #1's Order Audit Report, dated 06/16/2026, reflected the following order summary with order status, order date, start date, order signed by, and the strike out date if available: - REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, order noted as active, order dated 08/25/2025, order signed by NP B on 08/29/2025, and a strike out date was not entered. Record review of Resident #1's Medication Administration Record, printed 06/16/2026 and dated 06/01/2026 - 06/30/2026, reflected the orders:- APPLY LONG TERM WRAPS TO BILATERAL LEGS DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention therapy applies wraps while on services, order date 09/17/2025. The order was documented as administered from 06/01/2026 to 06/16/2026. - REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, order date 08/25/2025. The order was documented as administered from 06/01/2026 to 06/15/2026. Record review of Resident #1's Care Plan Report, undated and accessed 06/16/2026 at 4:48 p.m., reflected the following focus and interventions/tasks: - Focus: Has actual impairment to left anterior [left front] shin skin integrity r/t Edema [swelling caused by excess fluid trapped in the body's issues], date initiated 10/03/2024 and revised 01/09/2026. - Intervention/Task: APPLY LONG TERM WRAPS TO BILATERAL LEGS DAILY. every day shift every Mon, Tue, Wed, Thu, Fri, Sat, Sun for venous stasis prevention therapy applies wraps while on services, date initiated 01/09/2026. - Intervention/Task: REMOVE LONG TERM WRAP FROM BILATERAL LEGS. every evening shift for WOUND CARE PREVENTION, date initiated 01/09/2026. During an observation and interview on 06/17/2026 at 11:35 a.m., Resident #1 was observed in his room, lying in bed, with bed sheets covering his lower body. His leg wraps were not visible. Resident #1 stated his legs were wrapped. He did not clarify what type of wraps were on his legs. He stated sometimes the staff do not wrap his legs; it depended on what the therapist wanted. He stated he slept with his legs wrapped and they changed the wraps every day or every other day. He stated he did not have pain in his legs, resulting from lipedema (fat in his blood), because they wrapped his legs. During an interview on 06/17/2026 at 01:08 p.m., the Therapy Program Manager stated Resident #1 was receiving therapy Monday to Friday and on therapy days, therapy staff were putting on compression wraps. She stated it depended on where Resident #1 was in the lipedema treatment protocol (the type and degree of treatment would be customized to address the stage of symptoms) to determine if he would need to keep the compression wraps on during the night or not. She stated, typically the wraps were administered in the morning and then removed in the afternoon, and sometimes an additional type of wrap or specialized compression garment would be administered. She stated Resident #1 currently had his compression wraps put on in the morning and taken off in the afternoon because per his measurements, the measurement around his legs, Resident #1 was making good progress. She stated she would have to confirm with PT D to determine if therapy was exclusively administering Resident #1's wraps; however, most of the time the therapy staff administered them because they were more skilled in the lipedema protocols. She stated, right now the order stated therapy applied the wraps while Resident #1 was on service, but the administration of the order was more of a fluid thing, meaning it would depend on where the resident was in the treatment process. During an interview on 06/17/2026 at 01:50 p.m., PT D stated Resident #1 was receiving therapy Monday to Friday, five (5) days a week. PT D stated therapy applied Resident #1's wraps Monday to Friday and on Friday before the end of day, he would apply compression stockings for Resident #1 to wear over the weekend. PT D stated Resident #1 had the compression stockings taken off over last weekend, 06/13/2026- 06/14/2026, which resulted in Resident #1's legs having been really swollen by Monday. PT D stated if Resident #1 had a single wrapping on, then the weekend nurse would apply an additional Velcro wrap during the day, if Resident #1 allowed them. He stated Resident #1's nurse and he would communicate about what type of wraps were applied in therapy so the nurse would know if the wraps had been changed or not. During an interview on 06/17/2026 at 02:23 p.m., ADON E stated she understood that during the week Resident #1's wraps were administered by therapy staff and then nursing staff would remove them. During an interview on 06/17/2026 at 03:02 p.m., LPN C stated for Resident #1's wraps, they would sometimes be left on overnight or over the weekend, but Resident #1 would frequently request for the wraps to be removed. She stated the nurses would sometimes apply the Velcro wraps, but Resident #1 would frequently ask for them removed. She stated most of the time, if she saw Resident #1 had wraps applied by therapy, she would not change, add, or remove them unless he requested for them to be removed. She stated for Resident #1's wrap orders, they did not always match the current treatment procedure. She stated she read Resident #1's order as referring to the Velcro wrap the nursing staff applied, not the compression wrapping the therapist applied, which were different. She stated she would review the care plan to determine what wraps PT D was applying. She stated she did not believe that not following the order altered his care if Resident #1 was receiving the appropriate treatment. She stated the order not matching current treatment might impact Resident #1's care if he was provided care by a nurse that did not know Resident #1 and was unfamiliar with his care. During an interview on 06/17/2026 at 04:18 p.m., the DON stated Resident #1's wraps were usually provided by therapy during the week, and the therapist would coordinate with Resident #1's nurse, per the nurses' scope (area of practice the nurse is deemed competent). For the weekends, therapy was available, but PT D would coordinate with the nursing staff. He stated the nurses that provided Resident #1's care were consistent, so they were familiar with his current care. The DON stated he was unsure of the specifics of Resident #1's currently administered treatment but it would depend on Resident #1's treatment to determine if Resident #1 was impacted by the order not matching his current treatment. He stated he knew the therapists were treating Resident #1's lipedema and that the wraps being kept on long term was a normal part of the treatment procedure. He stated the order should be specific to the type of wrap that is applied. During an interview on 06/17/2026 at 04:55 p.m., the ADOR stated she and PT D had certifications to provide lipedema treatment. She stated the long-term wraps that were noted in Resident #1's order were for maintenance of the lipedema, to try to prevent the regression in Resident #1's leg circumference measurement, and they could be applied by the nursing staff. She stated the two-layer wraps could only be applied by a certified therapist or an assistant therapist trained in lipedema management. The ADOR stated, for Resident #1, the two-layer wraps could stay on Resident #1's legs for up to 72 hours, but it would depend on Resident #1's tolerance for the wraps. She stated if Resident #1 was seen by therapy, PT D might apply the two-layer wraps, depending on the treatment approach PT D determined to be appropriate that day. If Resident #1 was wrapped with the two-layer wraps, then the long-term wraps would not be applied on top of the two-layer wraps. She stated the long-term Velcro wraps could be applied if Resident #1 refused the two-layer wraps. She stated the inconsistency in treatment from the order was due to contributing factors, such as the treatment ordered was not appropriate for the resident's current treatment status. She stated if Resident #1 was wrapped with the two-layer wrap on Friday, since he could have the wrap on for up to 72 hours, the wrap could stay on until Monday, when PT D could assess Resident #1's legs and provide the treatment again. She stated the long-term wraps were essentially not applicable when the two-layer wraps were applied by therapy. She stated she could see that there could be a potential misunderstanding of what qualifies for the ordered wrap, such as checking off with what therapy administered versus the treatment noted in the order. She stated the nursing staff were given instruction that if Resident #1 received the two-layer wraps and had them on, then the long-term wraps would not be applied. She stated the nursing staff were not necessarily removing Resident #1's wraps each evening but if the ordered long-term wraps were applied, they were to be removed during the evening shift. Attempted interview on 06/17/2026 at 05:50 p.m. with MD A. NP B had the same office contact information as MD A. Office messaging system stated the office was closed for the day. During an interview on 06/17/2026 at 05:51 p.m., the ADOR stated the facility did not have a rehabilitation services policy or a lipedema policy. Record review of the facility's policy, Section Nursing Services and Subject Physician Orders, dated revised 05/2021 and last reviewed 08/2024, reflected: Policy: .It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Procedures .6. Medication, treatment or related procedure orders are transcribed in the medical record accordingly.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 4 residents (Residents #10, #13, #81 and #106) of 24 residents reviewed for MDS assessments. 1. The facility failed to ensure Resident #10 was coded Yes on her Quarterly MDS assessment, signed as completed on 01/14/2026, for Did the resident have a fall anytime in the last 2-6 months prior to admission/entry or reentry? because the resident had fall incident on 01/05/2026. 2. The facility failed to ensure Resident #13 and Resident #81's annual MDS was coded accurately for Preadmission Screening and Resident Review (PASRR). 3. The facility failed to ensure Resident #106's Annual MDS was coded accurately for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk of not receiving needed care and could result in missed or inappropriate care. The findings included: 2. Record review of Resident #13's face sheet dated 4/8/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13's diagnoses included major depressive disorder recurrent and moderate (recurring mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life moderate in severity), and PTSD (mental health condition that's caused by being a part of or witnessing an extremely stressful or terrifying event and symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). Record review of Resident #13's annual MDS assessment dated [DATE] revealed A1500 Preadmission Screening and Resident Review was coded as the resident did not have a serious mental illness and A1510 Level II Preadmission Screening and Resident Review was left blank. Record review of Resident #13's undated care plan revealed a focus initiated on 12/3/19 and revised on 10/16/24 for potential for psychosocial well-being problem related to diagnoses of depression and PTSD with interventions for psych and social services consults, monitoring, and anticipating needs. Another focus initiated on 10/3/24 for potential for re-traumatization related to the resident's PTSD being triggered by loud noises with interventions that included a revised intervention on 1/30/25 to provide a calm and quiet environment and notify the resident of fire alarm testing prior to alarms going off. Another focus initiated 12/3/19 and revised 10/16/24 for depression with interventions for monitoring and psychiatry consults In an interview on 4/10/26 at 10:57 a.m. LVN B stated Resident #13 did have a serious mental health diagnosis. LVN B stated it was coded incorrectly on the resident's annual MDS assessment dated [DATE] and it should have been coded as a yes and she was unsure how it was overlooked and could possibly delay needed services. Record review of Resident #81's face sheet dated 4/10/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #81's diagnoses included Down syndrome (a genetic condition caused by an extra copy of chromosome 21 (Trisomy 21), leading to physical traits like low muscle tone, small stature, and an upward slant to the eyes with mild-to-moderate intellectual disability and developmental delays). Record review of Resident #81's admission MDS assessment dated [DATE] revealed A1500 Preadmission Screening and Resident Review was coded as the resident did not have an intellectual disability or related condition and A1510 Level II Preadmission Screening and Resident Review was left blank. And A1550 Conditions Related to ID/DD Status Down syndrome was checked. The resident had unclear speech and was sometimes understood by others and sometimes understood others. The resident had a BIMS score of 00 indicating the resident was severely cognitively impaired. Record review of Resident #81's undated care plan revealed a focus initiated on 12/15/25 and revised on 1/22/26 for the resident receiving PASRR services, PASRR positive diagnosis: Down syndrome and had the name of the resident's habilitation coordinator listed. The interventions initiated 12/18/25 included IDT meeting to be completed as required, notify local authority of any significant changes, PASRR evaluation to be completed by local authority, and therapy services as ordered. In an interview on 4/10/2026 at 1:50 p.m. LVN B stated Resident #81's admission MDS assessment dated [DATE] was coded incorrectly, and she was unsure how it was overlooked. LVN B stated the MDS being coded incorrectly could delay needed services but the resident was not affected and her specialized services continued without interruption. 1. Record review of Resident #10's face sheet, dated 04/10/2026, revealed the resident was an 84-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of traumatic subdural hemorrhage (it is caused by a traumatic head injury, such as a blow to the head of a fall and bleeding inside the skull), dementia (loss of memory and thinking ability), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #10's Quarterly MDS assessment, dated 01/14/2026, revealed the resident's BIMS score was 6 out of 15 which indicated the resident had severe cognitive impairment. Section J (Health Conditions), the answered was coded No to the question Did the resident have a fall any time in the last 2–6 months prior to admission/entry or reentry? Record review of Resident #10's comprehensive care plan, dated 01/05/2026, revealed the resident had an actual fall with injury 1/5/26 with interventions 1/5/26 -Install scooped air mattress, fall mat and grab bars and Monitor/document /report to doctor for signs and symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Record review of Resident #10's incident report, dated 01/05/2026, revealed the resident fell from the bed grabbing something on the nightstand without asking help while CNA-C was providing bed bath to the resident on 01/05/2026. During an interview on 04/08/2026 at 12:25 PM, CNA-C stated on 01/05/2026 after dinner time, she was providing a bed bath to Resident #10. CNA-C stated she rolled the resident to the side, and had the resident grab the bed The resident was trying to grab something on the nightstand and suddenly fell from the bed. The CNA called the charge nurse immediately, and the charge nurse started assessing the resident. CNA-C said after the fall on 01/05/2026, the facility updated the care plans to prevent further fall such as fall mat, setting grab bar, scoop mattress, and two persons to assist activities of daily living for just in case, instead of one person. During an interview on 04/10/2026 at 10:22 AM, the MDS nurse LVN-B said Resident #10's quarterly MDS assessment, dated 01/14/2026, was inaccurate regarding coding as No to the question Did the resident have a fall any time in the last 2–6 months prior to admission/entry or reentry? in the Section J (Health Conditions) because the resident fell on [DATE]. The MDS nurse said the answer should have been coded Yes, it was her mistake. She said an inaccurate MDS could cause staff to provide inaccurate care to Resident #10. During an interview on 04/10/2026 at 2:27 PM, the DON said Resident #10 had fallen on 01/05/2026 and because of the incident, the facility had IDT meeting on 01/05/2026 and updated care plans. She said the updated care plans included fall mat, setting grab bar, scoop mattress, and two persons to assist activities of daily living instead of one person. 3. Record review of Resident #106's face sheet dated 04/08/2026, revealed Resident #106 was originally admitted to the facility on [DATE], with an admission date of 04/26/2024 with diagnoses that included: undifferentiated schizophrenia and moderate intellectual disabilities. Record review of Resident #106's Annual MDS assessment, dated 05/04/2025 Section A1500 Preadmission Screening and Resident Review (PASRR) coded 0 (No) for was the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Record review of Resident #106's care plan, revision date of 01/18/2026, revealed Resident #106 had a focus of Resident receiving PASRR services. PASRR positive diagnosis intellectual disability and developmental disability. Record review of Resident #106's PASRR Level 1 Screening, dated 03/01/2024, revealed, Section C PASRR Screening coded yes for Mental Illness, Intellectual Disability and Developmental Disability. During an interview and observation on 04/10/2026 at 10:40 a.m. LVN B stated Resident #106 was PASRR positive and had services. LVN B reviewed Resident #106's Annual MDS assessment and stated the May 2025 Annual MDS Assessment was coded incorrectly. LVN B further stated it should have been coded yes. LVN B stated Resident #106 had intellectual disability. LVN B stated that miscoding the MDS Assessment could cause a delay in services for residents. LVN B stated it was her responsibility for coding accuracy. LVN B further stated she had overlooked it, and this was why it was miscoded. During an interview on 04/10/2026 at 2:09 p.m. the Administrator stated that by not coding a resident's MDS as PASRR positive could increase the chance they might not have access to the PASRR services that the resident should have access to. The Administrator stated by the MDS Assessment being accurate could change the resident's plan of care and treatments they might get. The Administrator further stated MDS Assessment accuracy was the responsibility of MDS coordinators. Record review of facility's policy titled Resident Assessment and Associated Processes, revised date 12/2023, read, Policy: It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident.Procedure: Comprehensive Assessment: Includes the completion of the MDS (Minimum Data Set) as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change.An accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. Section A: Identification Information Intent: The intent of this section is to obtain the reasons for assessment, administrative information, and key demographic information to uniquely identify each resident.Coding instructions for A1550 Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #56) of 27 residents reviewed for dignity. The facility failed to ensure CNA-A did not stand next to Resident #56 while assisting the resident to eat during lunchtime on 04/07/2026. These failures could place the residents at risk of not having their right to a dignified existence maintained. Findings included: Record review of Resident #56's Face Sheet, dated 04/10/2026, reflected the resident was an [AGE] year-old female and originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of dementia (loss of memory and thinking ability), muscle wasting and atrophy (loss of skeletal muscle mass), and extrapyramidal and movement disorder (movement disorders that can develop as side effects of antipsychotic medications and continues spasm and muscle contractions). Record review of Resident #56's Quarterly MDS Assessment, dated 02/13/2026, reflected the resident's BIMS score was 0 out of 15 which indicated the resident had severe cognitive impairment and was unable to interview. Further record review of the Quarterly MDS Assessment indicated that the resident required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating. Record review of Resident #56's Comprehensive Care Plan, revision on 01/30/2025, reflected the resident required EATING - supervision assistance with meals. Observation on 04/07/2026 at 11:47 AM, revealed CNA-A was assisting Resident #56 for lunch in the dining area. CNA-A was standing next to the resident while she was feeding the resident. During an interview on 04/07/2026 at 11:55 AM, CNA-A stated she should be sitting down when she assisted somebody in the dining area. CNA-A said she was not assigned to help Resident #56 to eat and she was waiting for meal carts to be delivered on the halls, but she saw the resident did not eat her lunch very well, so just assisted the resident. CNA-A said when assisting somebody during mealtimes, she should sit down so she would be face to face with the resident. She said standing next to the resident was not a way of showing respect and dignity, and it was her mistake. During an interview on 04/09/2026 at 4:04 PM, the DON stated facility staff should sit down next to the resident when assisting them during mealtimes. The DON said not sitting beside the resident to assist in eating did not uphold dignity and respect. Record review of the facility's policy, titled Resident Rights, undated, revealed 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 2 medication rooms (Medication room station-2 for 100 and 500 hall) reviewed for medication storage. The facility failed to ensure the narcotic box inside the refrigerator for medications in the medication room station-2 for 100 and 500 hall was permanently affixed to the refrigerator. This failure could place residents at risk of not having controlled medications as ordered due to diversion of medication. Findings included:Observation on 04/08/2026 at 2:02 p.m. revealed there was a refrigerator inside the medication room station-2 for 100 and 500 hall, and the refrigerator was for medications. Further observation revealed one narcotic box for controlled medications was inside the refrigerator, but the narcotic box was affixed to one of refrigerator shelves, and the shelf was not permanently affixed to the refrigerator, so anybody could remove freely the shelf that the narcotic box was affixed to. Inside the narcotic box, there was one medication (Lorazepam injection pen). Interview on 04/08/2026 at 2:12 p.m. with ADON LVN-G he stated the narcotic box inside the refrigerator in the medication room station-2 for 100 and 500 hall was not permanently affixed, and anybody could remove it, but the facility had camera systems. The ADON said the narcotic box should have been permanently affixed to the refrigerator to prevent possible diversion of medication, and he would call maintenance right away to fix it. Interview on 04/09/2026 at 3:49 p.m. with DON revealed the narcotic box inside the refrigerator in the medication room station-2 for 100 and 500 hall should have been permanently affixed to the refrigerator to prevent possible diversion of medication. Record review of the facility policy, titled Controlled Medications - Storage and Reconciliation, review date on 12/2023, revealed It is the policy of this facility to safeguard access and storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse using separately locked, permanently affixed compartments with the exception that controlled mediations and those medications subject to abuse may be stored with non-controlled mediations as part of a single unit package mediation distribution system.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 27 residents (Resident #115) reviewed for care plans. The facility failed to ensure Resident #115's care plan reflected her bladder and bowel incontinence status and included a care plan regarding how to take care of the resident's bladder and bowel incontinence. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans. The findings included:Record review of Resident #115's face sheet, dated 04/10/2026, revealed a [AGE] year-old female, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels), and dementia (loss of memory and thinking ability). Record review Resident #115's admission MDS assessment, dated 01/20/2026, revealed the resident's BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment, and the resident was always incontinent of bladder and bowel. Record review of Resident #115's comprehensive care plan, dated 01/20/2026, revealed there was no care plan related to bladder and bowel incontinence care. Interview on 04/07/2026 at 12:04 p.m. with LVN-H stated Resident #115 had bladder and bowel incontinence and received bladder and bowel incontinence care. Interview on 04/10/2026 at 10:31 a.m. with the MDS nurse LVN-B stated she should have developed Resident #115's comprehensive care plan related to bladder and bowel incontinence care because the resident was always bladder and bowel incontinence. The MDS nurse LVN-B said she overlooked it, and it was her mistake, and no care plan potentially caused improper care to Resident #115. Record review of the facility policy, titled Comprehensive Person-Centered Care Planning, revision date 12/2023, revealed . 4. The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven days of completion of the MDS and will include resident's needs identified in the assessment, and any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan.

Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 27 Residents (Resident #10) whose records were reviewed for care plan revision/timing, in that: The facility failed to ensure Resident #10's care plan was updated after IDT meeting when the resident had a fall and changes to intervention where put in place to prevent fall from one person assist for baths to two persons assist on 01/05/2026. This failure could place residents at risk and contribute to residents not receiving the care and services they needed. The findings included:Record review of Resident #10's face sheet, dated 04/10/2026, revealed an 84-years-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of traumatic subdural hemorrhage (it is caused by a traumatic head injury, such as a blow to the head of a fall and bleeding inside the skull), dementia (loss of memory and thinking ability), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #10's Quarterly MDS assessment, dated 01/14/2026, revealed the resident's BIMS score was 6 out of 15 which indicated the resident had severe cognitive impairment, and Section GG (Functional Abilities) indicated the resident was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity) to shower/bathe. Record review of Resident #10's comprehensive care plan, revision on 01/30/2025, revealed the care plan for BATHING: the resident requires extensive one person assistance with Showering/Bathing. Review of the care plan, dated 01/05/2026, revealed the resident had an actual fall with injury 1/5/26 and for interventions 1/5/26 - Install scooped air mattress, fall mat and grab bars and Monitor/document /report to doctor for signs and symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Record review of Resident #10's incident report, dated 01/05/2026, revealed the resident fell from the bed to grab something on the nightstand without asking help while CNA-C was providing bed bath to the resident on 01/05/2026. Observation on 04/07/2026 at 11:20 a.m. revealed Resident #10 was on the bed and sleeping on the scooped air mattress, and there were grab bars and fall mat in place. During an interview on 04/08/2026 at 12:25 PM with CNA-C stated on 01/05/2026, after dinner time, she was providing a bed bath to Resident #10. CNA-C stated she rolled the resident to the side, and had the resident grab the bed. She stated the resident was trying to grab something on the nightstand and suddenly fell from the bed. CNA C stated she called the charge nurse immediately, and the charge nurse started assessing the resident. CNA-C said after the fall on 01/05/2026, the facility updated the care plans to prevent further fall such as fall mat, setting grab bar, scoop mattress, and two persons to assist activities of daily living, such as showering/bathing for just in case, instead of one person, and CNAs were to provide two persons assist to the resident for showering/bathing. During an interview on 04/10/2026 at 10:22 AM, the MDS nurse LVN-B said Resident #10 had two persons assist for showering/bathing after IDT meeting on 01/05/2026, but the care plan did not update correctly after IDT meeting. The MDS nurse LVN-B stated she had responsibility to update the care plan and not updating the care plan correctly was her mistake, and it should have been updated from one person to two persons after 01/05/2026, and not updating care plan might cause incorrect care. During an interview on 04/10/2026 at 2:27 PM, the DON said Resident #10 had fall incident on 01/05/2026, and because of the incident, the facility had an IDT meeting on 01/05/2026 and updated the care plans. She said the updated care plans included fall mat, setting grab bar, scoop mattress, and two persons to assist activities of daily living, such as showering/bathing for just in case, instead of one person. Record review of the facility policy, titled Comprehensive Person-Centered Care Planning, revision date 12/2023, revealed . 6. The resident's comprehensive plan of care will be revised and/or revised by the IDT after each assessment, including both comprehensive and quarterly review assessments.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 (Resident #39) of 2 residents reviewed for transfers in that: The facility failed to engage brakes of the mechanical lift when slowly lowering Resident #39 onto the bed on 04/09/2026. This failure could place residents at risk for falls, injuries, and decline in health. Findings included:Record review of Resident #39's face sheet, dated on 04/10/2026, revealed the resident was a 73-years-old female and admitted to the facility on [DATE] with diagnosis of fracture of lower and right femur (fracture to right thigh bone), muscle wasting and atrophy (loss of skeletal muscle mass), and obesity (complex disease involving having too much body fat). Record review of Resident #39's admission MDS assessment, dated on 02/11/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity) to chair to bed and toilet transfer in the Section GG (Functional Abilities). Record review of Resident #39's comprehensive care plan, dated on 02/10/2026, revealed TRANSFER (CHAIR/BED TO CHAIR TRANSFER, TOILET TRANSFER): Resident requires extensive 2-person assistance with Hoyer lift [mechanical lift] for transferring. Observation on 04/09/2026 at 11:17 a.m., revealed CNA-D and CNA-E transferring Resident #39 from wheelchair to bed with mechanical lift in the resident's room. CNA-D and CNA-E attached the sling straps to sling bar, lift the resident from the wheelchair, and slowly moved the lift to the bed. When CNA-E was lowering the resident onto the bed, CNA-E did not engage brakes of the lift, so the lift swung a little bit from side to side while CNA-D was gently holding Resident #39. The CNAs completed transferring Resident #39 from the wheelchair to the bed and left the room. Interview on 04/09/2026 at 11:24 a.m. with CNA-E stated she should have engaged brakes of the lift when lowering Resident #39 onto the bed for safety and to prevent possible incidents, and she had been trained on how to properly use the mechanical lift in 2025, and it was her mistake because she was very nervous. Interview on 04/09/2026 at 4:06 p.m. with DON said CNA-E should have engaged brakes of the lift when lowering Resident #39 onto the bed for safety. Record review of the facility policy and procedure, titled Transfers (Mechanical Lift), undated, revealed Base/Legs of [NAME] should be opened completely while lift is in motion. Engage brakes of lift after positioned. Slowly lower resident toward receiving surface.

Based on observation and interview, the facility failed to ensure a resident with an indwelling catheter, received the appropriate care and services for 1 of 3 residents (Resident #43) and the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #108), reviewed for quality of care. 1. The facility failed to ensure resident #43's urinary drainage bag remained below the level of the bladder during catheter care on 4/9/26.2. When CNA-F and CNA-C were providing incontinent care to Resident #108 on 04/09/2026, CNA-F did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region) and did not separate the resident's labia area. These failures could place residents at risk of cross contamination, urinary tract infections and complications. The findings were: 1. Record review of Resident #43's face sheet dated 4/10/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. Resident #43's diagnoses included Obstructive and reflux uropathy (structural or functional blockage of urine flow, and the backward flow of urine), and Benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate that commonly causes lower urinary tract symptoms). Record review of Resident #43's discharge return anticipated MDS assessment dated [DATE] revealed the resident BIMS score was blank, the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Record review of Resident #43's undated care plan revealed a focus initiated on 1/26/26 for an indwelling urinary catheter with interventions for catheter care every shift and to position the urinary drainage bag and tubing below the bladder. Record review of Resident #43's physician orders revealed an order with a start date of 1/30/26 for catheter care every shift. In an observation and interview on 4/9/26 at 3:10 p.m. Resident #43 was provided catheter care by MA I and CNA L. The resident was asked by CNA L if he wanted his brief changed and he stated that he would prefer it and as CNA L and MA I were assisting the resident to turn to his left side, MA I grabbed the urinary drainage bag by the hook at the top and held it in the air approximately 2.5 feet above the level of the resident's bladder and urine in the clear tubing drained back to the resident's bladder. MA I held the bag in the air until surveyor intervened and then placed it back down on the bed. The resident was also pointing and attempting to tell MA I to put the bag back down. CNA L was also observed telling MA I to put the urinary bag down on the bed. The resident denied any issues or concerns and the staff completed his care. In an interview on 4/9/26 at 3:26 p.m. MA I stated she was not supposed to lift the urinary drainage bag into the air or above the bladder and she knew that and had been trained but she was very nervous at the time and was not sure what to do with the urinary bag as she was drawing a blank due to being so nervous. In an interview on 4/9/26 at 4:09 p.m. the DON stated the staff had been trained not to lift the urinary drainage bag above the bladder and it was the standard of care not to raise it above the bladder. The DON stated raising it above the bladder could cause backflow of urine but the system was a closed system. Review of training and competencies revealed MA I was trained on catheter and perineal care on 9/2/25 and her skills competency for catheter care was completed and passed on 12/11/25. Review of the skill competency for catheter care only included what to do for the catheter care and did not include what not to do. Review of the facility policy on nursing staff competency revised 1/2022 did not address raising the urinary drainage bag above the bladder. Record review of Resident #108's face sheet, dated 04/10/2026, revealed the resident was a [AGE] year-old female, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (uncontrolled blood sugars), chronic kidney disease (kidneys have damage and less able to filter waste and fluid), and urinary tract infection (infection in any part of the urinary system such as bladder or urethra). Record review of Resident #108's quarterly MDS assessment, dated 01/13/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact, always incontinent of bladder, and frequently incontinence of bowel. Resident #108 required substantial/maximal assistance (helper does more than half the effort) to toilet transfer. Record review of Resident #108's comprehensive care plan, dated 11/24/2024, revealed [Resident #108] Has bowel/ bladder incontinence related to increased need of assistance with toileting due to generalized weakness with toileting. For intervention - INCONTINENT: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed for after incontinence episodes. Observation on 04/09/2026 at 2:56 p.m. revealed when CNA-C and CNA-F were providing perineal care to Resident #108, CNA-F opened the resident's old and dirty brief and cleaned the resident's left and right groin area and cleaned the resident's genital area without separating the labia. Further observation revealed CNA-F turned the resident to her left side without cleaning the suprapubic area, which was the area of the abdomen located below the umbilical region, and CNA-F cleaned the resident's buttock and rectum area, then put a new and clean brief on the resident. Interview on 04/09/2026 at 3:04 p.m. with CNA-F she stated she did not clean Resident #108's suprapubic area and did not separate the resident's labia area when cleaning the resident's genital area because she was nervous and forgot to clean the area and to separate the labia. CNA-F said she should have cleaned the area and separated the labia when providing peri-care to Resident #108 to prevent possible infection. Interview on 04/09/2026 at 4:07 p.m. the DON stated CNA-F should have cleaned Resident #108's suprapubic area and separated the labia area when providing peri-care to Resident #108 to prevent possible infection. Record review of the facility policy and procedure, titled Peri Care – Female, undated, revealed Wash genital area, moving from front to back, using a clean part of the washcloth for each stroke or a clean wipe for each stroke. After cleansing genital area, assist resident on side.

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 2 (Resident #3 and Resident #137) of 3 residents. 1. The facility failed to ensure Resident #3's oxygen tubing attached to the AVAP machine was bagged when not in use on 04/07/2026 and 04/08/2026. 2. The facility failed to ensure Resident #137's oxygen concentrator was set to 3 liters per minute as ordered by the physician on 04/8/2026. This failure could place residents at risk of illness, and respiratory complications.Findings included:1. Record review of Resident #3's face sheet, dated 04/08/2026, revealed she was admitted to the facility on [DATE], with an original admission date of 06/03/2025, with diagnoses which included: acute and chronic respiratory failure with hypoxia (sudden, severe worsening of baseline lung function in patients with chronic lung disease, resulting in critical oxygen deficiency), chronic obstructive pulmonary disease (a progressive, irreversible lung disease causing restricted airflow), and heart failure, unspecified. Record review of Resident #3's Quarterly MDS assessment, dated 02/05/2026, revealed the resident's BIMS score was 15, which indicated intact cognition. Section O Special Treatments, Procedures, and Programs revealed Section G1 Non-invasive Mechanical Ventilator was coded for Resident #3's AVAP use while a resident.Record review of Resident #3's care plan, initiated date of 06/06/2025, revealed a focus of Has altered respiratory status/Difficulty Breathing r/t Obstructive Sleep Apnea with an intervention of Apply CPAP machine with home settings at bedtime every evening . Record review of Resident #3's physician order summary report, dated, 04/08/2026, revealed a physician order reading Apply AVAP on QHS and off QAM, ensure AVAP is connected to oxygen when applying, at bedtime related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED and remove per schedule with a start date of 02/03/2026. Observation and interview on 04/07/2026 at 10:46 a.m. revealed Resident #3 lying in bed with the head of bed elevated wearing nasal cannula with oxygen concentrator set at 2 liter per minute and on the floor next to the oxygen concentrator was the oxygen tubing that was detached from the oxygen concentrator that led to Resident #3's AVAP machine. Resident #3 stated her oxygen should have been set to 2 liters per minute and she would wear her AVAP/CPAP machine at night. Resident #3 further stated her AVAP machine was hooked up to her oxygen concentrator at night. Observation on 04/08/2026 at 9:27 a.m. revealed Resident #3 lying in bed with oxygen nasal cannula on with oxygen concentrator set at 2 liters, and the oxygen tubing from her AVAP machine was looped up and stuffed in the handle to her oxygen concentrator not bagged. During an interview and observation on 04/08/2026 at 9:38 a.m. LVN M stated Resident #3's oxygen was supposed to be set at 2 liters per minute. LVN M stated the green oxygen tubing that went to her AVAP machine should have been bagged when it was not in use and further stated he would have to go get a bag for it. LVN M stated bagging the tubing prevented contamination. LVN M stated if the oxygen tubing was to get contaminated it could get in the tubing and possibly cause a respiratory infection. LVN M removed the oxygen tubing that was attached to the AVAP machine and stated it was due to it having been on the floor and he was going to replace it. During an interview on 04/09/2026 at 4:14 p.m. the DON stated the oxygen tubing should have been stored in a bag when not in use. The DON stated by bagging the oxygen when not in use reduced the chance of contamination. The DON further stated if it got contaminated there was a possibly of infections. During an interview on 04/10/2026 at 1:59 p.m. the Administrator stated the oxygen tubing was supposed to be bagged when not in use, to keep it clean and it would keep it from being contaminated. The Administrator stated everyone was responsible but on the day to day it would be the staff on the floor to ensure it was bagged and stored properly. 2. Record review of Resident #137's face sheet, dated 04/08/2026, revealed she was admitted to the facility on [DATE], with an original admission date of 12/17/2022, with diagnoses which included: chronic respiratory failure with hypoxia (sudden, severe worsening of baseline lung function in patients with chronic lung disease, resulting in critical oxygen deficiency), chronic obstructive pulmonary disease (a progressive, irreversible lung disease causing restricted airflow), and hypoxic ischemic encephalopathy (brain injury caused by oxygen deprivation (hypoxia) or reduced blood flow (ischemia)), unspecified.Record review of Resident #137's Quarterly MDS assessment, dated 02/03/2026, revealed the resident's BIMS score was 13, which indicated borderline cognitive impairment. Section O Special Treatments, Procedures, and Programs revealed Section C1 Oxygen Therapy was coded for Resident #137's oxygen use while a resident.Record review of Resident #137's care plan, initiated date of 08/06/2025, revealed a focus of Has COPD (Chronic Obstructive Pulmonary Disease) and Chronic Hypoxia with an intervention of Give oxygen therapy as ordered by the physician. Record review of Resident #137's physician order summary report, dated, 04/08/2026, revealed a physician order reading O2 at 3 L/MIN CONTINUOUS PER nasal cannula every shift with a start date of 07/25/2025. Observation and interview on 04/08/2026 at 9:53 a.m. revealed Resident #137 sitting up in her wheelchair working with a knitting loom wearing her nasal cannula and oxygen concentrator set at 2.5 liters per minute. Resident #137 stated it was supposed to be set at 3 liters per minute and that the staff had been setting the oxygen concentrator between 3 and 4 liters per minute. During an interview and observation on 04/08/2026 at 10:01 a.m. LVN M stated Resident #137's oxygen concentrator was supposed to be set at 3 liters per minute then LVN M checked the concentrator, stated it was set at 2.5 liters per minute and then adjusted it to 3 liters per minute. LVN M stated if Resident #137 was exerting herself and oxygen was not at the proper setting of liters Resident #137 could possibly become hypoxic. LVN M further stated this could cause a lack of oxygen and it could possibly cause a resident to go into respiratory distress. During an interview on 04/09/2026 at 4:16 p.m. the DON stated the facility needed to follow the orders and the orders were typically based on the residents' O2 needs. The DON stated by Resident #137's oxygen concentrator not being set at the proper setting Resident #137 could become short of breath by the oxygen not being set as ordered. During an interview on 04/10/2026 at 2:07 p.m. the Administrator stated oxygen would be considered a medication and the nurse on the floor would be responsible to ensure it was at the proper setting. The Administrator stated that by not having Resident #137's oxygen concentrator at the proper setting it could possibly cause Resident #137's oxygen level to not be high enough and she could possibly desat (A drop in hemoglobin oxygen saturation). Review of the policy on Oxygen provided by the facility revised on 05/2007 did not address the oxygen tubing. Record review of facility's policy titled Oxygen Administration (Mask, Cannula, Catheter),, revised date 05/2007, read, Policy: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (400-hall nursing cart) of 6 medication carts reviewed for medication storage and for 1 (Resident #134) of 10 residents reviewed for medication administration. 1. There was one bottle of blood glucose test strips inside the 400-hall nursing cart on [DATE], and the test strips expired on [DATE]. 2. The facility failed to reorder Resident #134's buspirone hydrochloride 7.5 MG Oral Table for depression on time. As a result, the medication was not available when administering the medication to the resident. This failure could place the residents at risk of not receiving therapeutic doses of their medication. Findings included:1. Observation on [DATE] at 3:01 p.m. revealed there was one bottle of blood glucose test strips inside the 400-hall nursing cart, and the test strips expired on [DATE]. Further observation revealed there was a date written with red marker on the bottle of the glucose test strips, and the date was [DATE]. Interview on [DATE] at 3:02 p.m. with LVN-H stated the date ([DATE]) written with red marker on the bottle of glucose test strips was the open date and used the test strip since [DATE]. LVN-H said she did not know the test strips expired on [DATE] because she did not check the expiration date, and it was her mistake. LVN-H stated she should have checked the expiration date of the test strips and should not have used them because they expired on [DATE], and the nurse said residents on 400-hall did not have any negative outcome related to blood glucoses, but nurses should not use expired blood glucose test strips to have accurate blood sugar values. Interview on [DATE] at 3:49 p.m. with DON revealed the facility nurses should have checked the expiration date of the blood glucose test strips and should not have used the strips if the strips were expired to have accurate blood sugar values. 2. Record review of Resident #134's face sheet, dated on [DATE], revealed the resident was a [AGE] year-old male and admitted to the facility on [DATE] with diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), major depressive disorder (persistently low or depressed mood and interest in pleasurable activities), and anxiety disorder (symptoms of intense anxiety or panic that are directly by a physical health problem). Record review of Resident #134's annual MDS assessment, dated [DATE], revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognitive was intact and in the Section N (Medications) the resident was receiving antidepressant. Record review of Resident #134's comprehensive care plan, dated [DATE], revealed the resident had the care plan of At risk for depression related to history of major depressive disorder. For intervention - Administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #134's physician order, started on [DATE], revealed the resident had the order of busPIRone hydrochloride Oral Tablet 7.5 MG (Buspirone hydrochloride) Give 1 tablet by mouth two times a dayfor agitation related to MAJOR DEPRESSIVE DISORDER. Record review of Resident 134's Medication Administration Record from [DATE] to [DATE] revealed Resident #134 was receiving his busPIRone hydrochloride 7.5 mg by mouth one tablet for depression every morning and every hour of sleep. Observation on [DATE] at 8:44 a.m. revealed MA-I prepared Resident #134's morning medications and could not find the resident's busPIRone hydrochloride for depression in the cart. MA-I reported to RN-J regarding she could not find Resident #134's busPIRone hydrochloride for depression, and RN-J searched the medication room and the facility emergency kit, but RN-J said she could not find the medication, and the facility emergency kit did not have the medication, so the nurse would contact the resident's primary care physician and pharmacy. Further observation on [DATE] at 9:13 a.m. revealed MA-I notified Resident #134 regarding the medication was not available and said whenever she got the medication, she would give it to the resident, and the resident said he was fine. Interview on [DATE] at 9:00 a.m. with MA-I she said she did not know what reason the medication was not available because she usually did not work at the 600-hall, but the facility nurses or medication aides should have reordered the medication at least 5 days ago before the medication ran out. Interview on [DATE] at 9:10 a.m. with RN-K she said she was the charge nurse of Resident #134, and nurses or medication aides should have reordered the resident's busPIRone hydrochloride for depression at least 5 days ago before the medication ran out, and if the resident did not take the medication, the resident might have increased signs and symptoms related to depression. Interview on [DATE] at 3:48 p.m. with DON said the facility nurses reported about Resident #134's busPIRone hydrochloride for depression was not available, so he called to the facility pharmacy, and the pharmacy delivered the medication right away, and the resident took the medication within time frame because the pharmacy was located very close to the facility. However, nurses or medication aides should have reordered the resident's busPIRone hydrochloride for depression at least 5 days ago before the medication ran out per the facility policy. Record review of the facility policy, titled Physician orders, reviewed on 08/2024, revealed . 9. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy prior to the last dosage being administered to assure that refills are on hand.

Based on interview and record review, the facility failed to ensure medical records on each resident were complete, readily accessible, and contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State for 2 of 5 residents (Resident #13, and #81), reviewed for Administration. 1. The facility failed to ensure Resident #13's PASARR level 1 screening, and PASARR level 2 evaluation were included in the resident's EHR. 2. The facility failed to ensure Resident #81's PASARR level 2 evaluation, and her specialized service plans were included in the resident's EHR. This failure could place residents at risk of a delay in or not receiving their needed care and specialized services, and decreased continuity of care.The findings were: 1. Record review of Resident #13's face sheet dated 4/8/26 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13's diagnoses included major depressive disorder recurrent and moderate (recurring mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life moderate in severity), and PTSD (mental health condition that's caused by being a part of or witnessing an extremely stressful or terrifying event and symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). Record review of Resident #13's annual MDS assessment dated [DATE] revealed A1500 Preadmission Screening and Resident Review was coded as the resident did not have a serious mental illness and A1510 Level II Preadmission Screening and Resident Review was left blank. Record review of Resident #13's undated care plan revealed a focus initiated on 12/3/19 and revised on 10/16/24 for potential for psychosocial well-being problem related to diagnoses of depression and PTSD with interventions for psych and social services consults, monitoring, and anticipating needs. Another focus initiated on 10/3/24 for potential for re-traumatization related to the resident's PTSD being triggered by loud noises with interventions that included a revised intervention on 1/30/25 to provide a calm and quiet environment and notify the resident of fire alarm testing prior to alarms going off. Another focus initiated 12/3/19 and revised 10/16/24 for depression with interventions for monitoring and psychiatry consults. Record review of Resident #13's EHR revealed there was no evidence a PASSAR level 1 screening, or a PASSAR level 2 evaluation had been completed in the resident's medical record. Record review of iQIES survey environment indicated Resident #13's MDS triggered for no PASSR level 2 evaluation with a qualifying diagnosis. Record review of Resident #13's EHR revealed the resident's PASSR negative level 2 evaluation dated 10/3/24 was uploaded to the resident's medical record on 4/10/26. 2. Record review of Resident #81's face sheet dated 4/10/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #81's diagnoses included Down syndrome (a genetic condition caused by an extra copy of chromosome 21 (Trisomy 21), leading to physical traits like low muscle tone, small stature, and an upward slant to the eyes with mild-to-moderate intellectual disability and developmental delays). Record review of Resident #81's admission MDS assessment dated [DATE] revealed A1500 Preadmission Screening and Resident Review was coded as the resident did not have an intellectual disability or related condition and A1510 Level II Preadmission Screening and Resident Review was left blank. And A1550 Conditions Related to ID/DD Status Down syndrome was checked. The resident had unclear speech and was sometimes understood by others and sometimes understood others. The resident had a BIMS score of 00 indicating the resident was severely cognitively impaired. Record review of Resident #81's undated care plan revealed a focus initiated on 12/15/25 and revised on 1/22/26 for the resident receiving PASRR services, PASRR positive diagnosis: Down syndrome and had the name of the resident's habilitation coordinator listed. The interventions initiated 12/18/25 included IDT meeting to be completed as required, notify local authority of any significant changes, PASRR evaluation to be completed by local authority, and therapy services as ordered. Record review of iQIES survey environment indicated Resident #81's MDS triggered for no PASSR level 2 evaluation with a qualifying diagnosis. Record review of the facility provided list of PASRR positive residents revealed Resident #81 was on the list and received specialized services. Record review of Resident #81's EHR on 4/9/26 at 11:18 a.m. and 4/10/26 at 10:00 a.m. revealed there was no PASSAR level 2 evaluation, and no IP or HSP completed in the resident's medical record indicating she received specialized services. Record review of Resident #81's EHR revealed Resident #81's PASSAR level 2 evaluation, and her IP dated 1/22/26 and her HSP dated and signed by the LIDDA Habilitation coordinator on 1/22/26 were uploaded to the medical record on 4/10/26. In an interview on 4/10/26 at 2:18 p.m. the DON stated the HSP and IP should have been in Residents medical record and was not sure why it had not been uploaded previously. The DON stated this did not affect the residents and Resident #81 continued to receive specialized services uninterrupted. Facility Policy on medical record content provided by the facility revised 3/2019 did not address PASSR records.

Based on observation, interview, and record review, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Residents #1) of 27 residents reviewed, in that: Resident #1's personal refrigerator located in her room contained a small plastic container and some food wrapped with kitchen aluminum foil with no date and no label on 04/07/2026. The failure could place the residents at risk for food borne illness. The findings included:Record review of Resident #1's face sheet, dated 04/10/2026, revealed the resident was a [AGE] year-old female originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of pneumonia (infection that affects one or both lungs), dysphagia (difficulty swallowing), and muscle wasting and atrophy (decrease in muscle size and mass, which results in reduced muscle strength and function). Record review of Resident #1's Medicare 5-days MDS assessment, dated 02/19/2026, revealed the resident's BIMS score was 15 out of 15, which indicated the resident's cognitive was intact. Further record review of the MDS assessment revealed the resident required setup or clean-up assistance (Helper sets up or cleans up; resident completes activity.Helper assists only prior to or following the activity) for eating. Record review of Resident #1's comprehensive care plan, dated 01/21/2026, revealed the resident had the care plan of REGULAR diet, REGULAR texture, THIN LIQUIDS consistency and Explain and reinforce to the importance of maintaining the diet ordered. Encourage to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Observation on 04/07/2026 at 10:40 a.m. revealed Resident #1 was on her wheelchair and watching television in her room. There was a personal refrigerator in the room, and inside the refrigerator there was a small plastic container with food and some food wrapped with kitchen aluminum foil, but no date and no label were on the container and wrap. Interview on 04/07/2026 at 10:41 a.m. with Resident #1 said the food inside the small plastic container and wrapped with kitchen aluminum foil was apple pie, and the resident's daughter brought the food, but the resident said she did not know when her daughter brought the food. Interview on 04/07/2026 at 12:06 p.m. with LVN-H stated Resident #1's refrigerator in her room had a small plastic container with food and some food wrapped with kitchen aluminum foil, but they were not dated and labeled. LVN-H said that she did not know what this food was and how long the food was inside the refrigerator because of no label and date, and the nurse said the facility night nurses were supposed to check it every day. Interview on 04/09/2026 at 3:48 p.m. the DON stated facility nurses were responsible for overseeing Resident #1's personal refrigerator and also responsible for monitoring it daily and should have dated and labeled the food that the family member brought. The DON stated the resident might have food illness. Record review of the facility policy, titled Resident Personal Food Storage, review dated on 01/2022, revealed Food or beverage brought in from outside sources for storage in facility pantries, refrigerator units or personal/resident room refrigerator units will be monitored by designated facility staff for food safety.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for plate preparation. The facility failed to ensure dietary staff properly air-dried insulated domes for tops of plates prior to meal service observed on 04/09/2026. These failures could place residents who received meals and/or snacks from the kitchen at risk of food born illness. The findings included: Observation on 04/09/2026 at 11:29 a.m. revealed Dietary Aide N placing plates on trays once they were prepared and covering them with insulated domes that had pooling water in them and as the Dietary Aide N would turn them over and place them on the plates of approximately 7 plates water would dribble across the plates. Dietary Aide N would then place the trays on the rack that were sent to 600 hall. Observation and interview on 04/09/2026 at 11:37 a.m. the Dietary Supervisor observed the insulated domes being placed on plates, that had not been dried properly and instructed the Dietary Aide N to remove the wet lids from the serving area so they could be racked and allowed to dry thoroughly. The Dietary Supervisor stated the Dietary Aide O was new and possibly had not allowed them enough time to dry as she was responsible for pulling the clean dishes when they finished washing and putting them away. The Dietary Supervisor further stated they did not have large drying racks to place the trays and lids on but would let them dry in the dish rack they would send through the dishwasher. The Dietary Supervisor stated the lids should be allowed to air dry totally. The Dietary Supervisor further stated this was to prevent residents from getting sick and prevent the dishwater from getting on the food. During an interview on 04/09/2026 at 11:40 a.m. the Dietary Aide N stated that by not drying the lids all the way it could allow for water to drip in the food and this could cause stomach upset for the residents. During an interview on 04/09/2026 at 11:42 a.m. the Dietary Aide O stated by not allowing the lids to dry all the way it could allow for bacteria growth from the moisture. The Dietary Aide O further stated this could possibly cause residents to get sick. During an interview on 04/10/2026 at 2:13 p.m. the Administrator stated before insulated domes were put in use, they should have been fully dried to prevent contamination issues. The Administrator stated the staff in the kitchen were responsible for ensuring they have dried properly. Review of facility's policy, Mechanical Warewashing: Dish Machines, no date, read Machine Warewashing Techniques: Air-dry all items. Towels may contaminate items.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for accurate administration of medications. The facility failed to ensure Resident #1's mediation order of cloNIDine HCI (a medication used to treat blood pressure and/or heart rate) was entered as prescribed by a physician. This failure could place residents at risk of not receiving their prescribed medications correctly and a decreased quality of life.The findings include: Record review of Resident #1's face sheet dated 3/30/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension (high blood pressure), heart failure, unspecified (heart is not pumping effectively), and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #1's BIMS assessment dated [DATE] reflected a BIMS score of 6 out of 15 indicating severe cognitive impairment. Record review of Resident #1's Order Summary Report dated 3/30/2026 reflected the following: cloNIDine HCl Oral Tablet 0.1 MG (Clonidine HCl) Give 1 tablet by mouth two times a day for HTN hold is systolic BP is less than 110, pulse or diastolic less than 60 with a start date of 3/26/2026 Record review of Resident #1's MAR for March 2026 reflected the following for cloNIDine HCl: medication administration of cloNIDine HCl on 3/26/2026 with Resident #1's blood pressure as 142/52 and pulse 58. Record review of Resident #1's hospital paperwork dated 3/25/2026, used to admit Resident #1 to the facility, revealed cloNIDine 0.1 MG tablet Take 0.1 mg by mouth 2 (two) times daily as needed (HTN). During an interview on 3/30/2026 at 3:30 p.m., CMA C stated she gave Resident #1 all her prescribed blood pressure medications on 3/26/2026 as ordered but could not remember the names of them. CMA C stated there were no parameters on the medication order. CMA C stated she was not aware at the time of a PRN blood pressure medication. During an interview on 3/30/2026 at 4:37 p.m., RN A stated she was the nurse who admitted Resident #1 to the facility. RN A stated she sent the list of medications received from the hospital to the NP who then approved the medications. RN A stated she then put those medication orders into Resident #1's electronic record. RN A stated when she returned to work, on a different day, she was told a medication was placed into the electronic record incorrectly and that it was put in as scheduled when it should have been PRN. RN A stated the risk of entering a medication incorrectly could be a medication error and pain to the resident if it was given. During an interview on 3/31/2026 at 9:02 a.m., the NP stated she was familiar with Resident #1 and was Resident #1's NP. The NP stated she approved the medication list sent to her by the facility when Resident #1 admitted to the facility. NP stated the cloNIDine HCl should have been a PRN medication and not entered as scheduled medication. NP stated it should be entered as PRN due to the option of it being held or staggered dependent on the resident's blood pressure/pulse readings. During an interview on 3/31/2026 at 4:16 p.m., the DON stated the nurse who admitted the resident should validate their medication orders with the doctor to see if the doctor wants the resident to continue or change any medications. The DON stated the risk of not inputting orders accurately as prescribed from the doctor could be a resident having a change in condition. During an interview on 3/31/2026 at 4:40 p.m., Resident #1 stated they usually take a lot of blood pressure medications but could not remember which medications they received on 3/26/2026. Record review of the facility document titled Administration of Medication, revised in 2022, reflected: Policy:It is the policy of this facility that medications shall be administered as prescribed by the attending physician.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled for 1 of 3 residents (Resident #1) reviewed for medication labeling. 2. An insulin flex pen (Aspart) for diabetes had no resident's name labeled and was found on the 400-hall medication cart on 06/03/2024 and assumed by LVN A to belong to Resident #1. This failure could place residents at risk of use of the medication for more than one resident which could result in contamination of a blood borne pathogen. The findings included: Record review of Resident #1's face sheet, dated 06/03/2025, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: cerebral palsy (a group of neurological disorders that affect movement, balance and posture), type 2 diabetes mellitus (the most common form of diabetes characterized by the body's inability to properly use insulin, leading to high sugar levels), mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking), anxiety (a feeling of worry, unease, or nervousness, often accompanied by physical symptoms like a racing heart or rapid breathing and need for assistance with personal care. Record review of Resident #1's Annual MDS assessment, dated 05/04/2025, revealed the resident rarely or never understood others and could rarely or never understand. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for her ADLs, and she received insulin injections daily. Record review of Resident #1's physician's order, dated 12/27/2024, revealed the resident had the order of Fiasp (brand name) Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart (with Niacinamide, a form of Vitamin B3) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously with meals for DM If greater than 401notify MD Phone Active 03/25/2025. Record review of Resident #1's MAR, dated from 06/01/2025 to 06/30/2025, revealed Resident #1 was receiving Fiasp Pen Fill subcutaneous Solution Pen Injector 100 unit/ml (insulin Aspart) inject as per sliding scale. Observation on 06/03/2025 at 12:15 p.m. revealed LVN A proceeded to administer Resident #1 her PRN insulin. The insulin pen was lying on a medication tray, had an open date of 05/20/25 and an expiration date. The insulin pen which was Aspart, 100 UNITS/ML did not have Resident #1's name. In an interview on 06/03/2025 at 12:17 p.m., LVN A, stated she usually labels the pens with the resident's names and did not know why the insulin pen was not labeled. Observation on 06/03/2025 at 12:19 p.m. revealed LVN A writing with a marker, Resident #1's name on the Aspart insulin pen. In an interview on 06/03/2025 at 12:20 p.m., LVN A, stated she knew the Aspart insulin pen belonged to Resident #1 because she was the only resident on the 400 Hall with that type of insulin. Observation on 06/03/2025 at 12:24 p.m. of LVN A, she proceeded to administer Resident #1 4 units of the Aspart insulin as ordered for her blood sugar sliding scale. In an Interview on 06/03/2025 at 12:46 p.m., the DON, stated insulin pens needed to be labeled. He said he was not aware Resident #1's pens were not labeled. He stated Resident #1's family brought in her insulin and the pen should not be placed on the medication cart without her name. He stated the consequences could be cross contamination of a blood borne pathogen. He stated the unlabeled insulin pen needed to be discarded when LVN A found it on the cart. Interview on 06/04/2025 at 12:50 p.m., LVN A, stated Resident #1's insulin pens was provided by the family and the family member would label them. She did not know how the pen was on the medication cart without a resident label. Interview on 06/04/2025 at 1:36 p.m. with the ADON, he stated when insulin pens arrived at the facility they were logged in and accounted for, however, he had not encountered an unlabeled one. He stated Resident #1's family brought the insulin in and must have missed labeling one of the pens. He stated he did not know how it was found on a cart without a label. He stated it would be difficult to identify whose medication it was without a label and would not be safe. Interview on 06/04/2025 at 2:08 p.m. with RN B, she stated an unlabeled insulin pen in the medication cart needed to be discarded. Record review of the facility policy and procedure titled Section: Medication Administration, Subject: Administration of Medication dated revised 07/2013 and reviewed 06/2022 reflected The seven rights of medication administration are as follows to ensure safety and accuracy of administration, 1. Right Resident, 2. Right Time, 3. Right Medication, 4. Right Dose, 5. Right Route, 6. Right Documentation and 7. Right Diagnosis. Record review of the facility policy and procedure titled Section: Care and Treatment, Subject: Medication Access and Storage revised 05/2025 reflected: Medications labeled for individual residents are stored separately from floor stock medications.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services. LVN A administered Resident #1's insulin from a flex pen (Aspart) for diabetes at lunchtime to Resident #1, when it was not labeled with the resident's name. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Record review of Resident #1's face sheet, dated 06/03/2025, revealed she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: cerebral palsy (a group of neurological disorders that affect movement, balance and posture), type 2 diabetes mellitus (the most common form of diabetes characterized by the body's inability to properly use insulin, leading to high sugar levels), mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking), anxiety (a feeling of worry, unease, or nervousness, often accompanied by physical symptoms like a racing heart or rapid breathing and need for assistance with personal care. Record review of Resident #1's Annual MDS assessment, dated 05/04/2025, revealed the resident rarely or never understood others and could rarely or never understand. She was not a candidate for a BIMS which indicated she was severely cognitively impaired. She was dependent on staff for her ADLs, and she received insulin injections daily. Record review of Resident #1's physician's order, dated 12/27/2024, revealed the resident had the order of Fiasp (brand name) Pen Fill Subcutaneous Solution Cartridge 100 UNIT/ML (Insulin Aspart (with Niacinamide, a form of Vitamin B3) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously with meals for DM If greater than 401notify MD Phone Active 03/25/2025. Record review of Resident #1's MAR, dated from 06/01/2025 to 06/30/2025, revealed Resident #1 was receiving Fiasp Pen Fill subcutaneous Solution Pen Injector 100 unit/ml (insulin Aspart) inject as per sliding scale. Observation on 06/03/2025 at 12:15 p.m., revealed LVN A proceeded to administer Resident #1 her insulin. The insulin pen was lying on a medication tray, had an open date of 05/20/25 and an expiration date. The insulin pen which was Aspart, 100 UNITS/ML did not have Resident #1's name. In an interview on 06/03/2025 at 12:17 p.m., with LVN A she stated she usually labels the pens with the resident's names and did not know why the insulin pen was not labeled. Observation on 06/03/2025 at 12:19 p.m., revealed LVN A writing with a marker, Resident #1's name on the Aspart insulin pen. In an interview on 06/03/2025 at 12:20 p.m., LVN A, stated she knew the Aspart insulin pen belonged to Resident #1 because she was the only resident on the 400 Hall with that type of insulin. Observation on 06/03/2025 at 12:24 p.m., LVN A, proceeded to administer Resident #1 4 units of the Aspart insulin as ordered for her blood sugar sliding scale. In an Interview on 06/03/2025 at 12:46 p.m., the DON, stated insulin pens needed to be labeled. He said he was not aware Resident #1's pen was not labeled. He stated Resident #1's family brought in her insulin and the pen should not be placed on the medication cart without her name. He stated he was accountable for the nursing care at the facility and nurses were trained on the 6 rights of medication administration. He stated it was not acceptable to administer insulin to Resident #1 without a name on the insulin pen or assume an unlabeled pen belonged to a specific resident. He stated the consequences could be cross contamination of a blood borne pathogen. He stated the unlabeled insulin pen needed to be discarded when LVN A found it on the cart. Interview on 06/04/2025 at 12:50 p.m., LVN A, stated she knew not to give residents medications that was unlabeled. She stated she was trained not to do that, and did not think about it at the time, but the consequences could be cross contamination. Interview on 06/04/2025 at 1:36 p.m., the ADON, stated when insulin pens arrived at the facility they were logged in and accounted for, however, he had not encountered an unlabeled one. He stated Resident #1's family brought the insulin in and must have missed labeling one of the pens. He stated he did not know how it was found on a cart without a label. He stated he trained LVN A and provided a skills checklist which she completed. Record review of LVN A's medication administration skills checklist dated 12/12/2024 reflected Pre-Administration, gather medication for one resident at a time while adhering to the six rights of medication administration (drug, dose, route, time, resident and documentation), select correct drug and compare name on medication label with the MAR. Record review of the facility policy and procedure titled Section: Medication Administration, Subject: Administration of Medication dated revised 07/2013 and reviewed 06/2022 reflected The seven rights of medication administration are as follows to ensure safety and accuracy of administration, 1. Right Resident, 2. Right Time, 3. Right Medication, 4. Right Dose, 5. Right Route, 6. Right Documentation and 7. Right Diagnosis.

39049 Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 residents (Residents #52, #109, and #27) of 29 residents and for 1 of 2 shower rooms (600 W hallway) reviewed for infection control practices. 1. LVN-C provided colostomy (opening for the colon through the belly) care for Resident #52 and failed to change her gloves without sanitizing or washing her hands. 2. LVN-A entered Resident #109's room, who was on EBP, on 02/19/2025 at 4:40 p.m. and failed to put on a gown when the LVN-A was administering medications to the resident via gastrostomy tube. 3. Medication Aide-I administered medications for high blood pressure to Resident #27, the Medication Aide-I used a blood pressure cuff of the monitor machine to take Resident #27's blood pressure without cleaning the cuff. 4. Nursing staff failed to remove a washcloth full of feces and sanitize the shower stall after showering residents. These deficient practices affect residents who require assistance treatments and could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #52's face sheet, dated 02/21/2025, revealed the resident was an [AGE] year old female and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of paraplegia (inability to voluntarily move the lower pasts of the body), asthma (airways become inflamed, narrow, and swell which makes it difficult to breathe), chronic respiratory failure (shortness of breath of feeling like you cannot get enough air), muscle wasting and atrophy (loss of muscle tissue and strength), and sleep apnea (breathing stops and restarts many times while sleeping). Record review of Resident #52's quarterly MDS assessment, dated 02/02/2025, revealed the resident's BIMS was 15 out of 15 indicated her cognition was intact, the resident had colostomy. Record review of Resident #52's comprehensive care plan, dated 07/01/2024, revealed the resident had Had an alteration in gastrointestinal status related to colostomy. For intervention - Change colostomy flange every 3 to 5 days and as needed and empty colostomy bag every shift and when half full and as needed. Observation on 02/20/2025 at 2:00 p.m. revealed LVN-C was providing colostomy care to Resident #52. After LVN-C removed the old colostomy bag, LVN-C changed her gloves without sanitizing or washing her hands. LVN-C started cleaning the stoma (small opening in the abdomen that is used to remove body waste), patted dry, and applied skin prep around the stoma. Then, LVN-C changed her gloves again without sanitizing or washing her hands and put the new colostomy bag on Resident #52. Interview on 02/20/2025 at 2:19 p.m. LVN-C stated she removed the old colostomy bag and changed her gloves without sanitizing or washing her hands, then started cleaning the stoma, patted dry, and applied skin prep around stoma. LVN-C the nurse changed her gloves again without sanitizing or washing her hands and put the new colostomy bag to Resident #52. Further interview, LVN-C stated she should have sanitized or washed her hands when she changed gloves to prevent possible infection. Interview on 02/20/2025 at 4:00 p.m. the DON stated LVN-C should have sanitized or washed her hands when each time she changed her gloves to prevent possible infection. 2. Record review of Resident #109's face sheet, dated 02/21/2025, revealed the resident was a [AGE] year old male, admitted to the facility on [DATE], and readmitted to the facility on [DATE] with the diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), gastro esophageal reflux disease (stomach acid or bile irritates the food pipe lining), muscle wasting and atrophy (loss of muscle tissue and strength), dysphagia (difficulty of swallowing), and gastrostomy (creation of an artificial external opening into stomach). Record review of Resident #109's quarterly MDS assessment, dated 01/22/2025, revealed the resident's BIMS was 0 out of 15 which indicated the resident had severe cognitive impairment, and the resident had a feeding tube. Record review of Resident #109's comprehensive care plan, dated 02/05/2025, revealed the resident Had potential nutritional problem requires tube feeding related to dysphagia and For intervention - Use Enhanced Barrier Precautions. Observation on 02/19/2025 at 4:40 p.m. revealed there was the sign of Enhanced Barrier Precaution over the head of Resident #109's bed and indicated to put on gloves and gown when providing high-contact resident care activities such as feeding tube. When LVN-A administered medications to the resident via gastrostomy tube, the LVN-A did not wear a gown. Interview on 02/19/2025 at 4:57 p.m. LVN-A stated when she administered medications to Resident #109 via gastrostomy tube, she did not wear a gown because she forgot to. Further interview, LVN-A said she should have put on a gown because the resident had enhanced barrier precautions which indicated putting on gloves and gown when providing high-contact resident care activities such as a feeding tube to prevent possible infections. Interview on 02/20/2025 at 4:00 p.m. the DON stated LVN-A should have put on a gown because Resident #109 had enhanced barrier precautions which indicated putting on gloves and gown when providing high-contact resident care activities such as a feeding tube to prevent possible infections. 3. Record review of Resident #27's face sheet, dated 02/21/2025, revealed the resident a [AGE] year old male, admitted to the facility on [DATE], and readmitted to the facility on [DATE] with the diagnoses of schizophrenia (disorder that affects a person's ability to think), dysphagia (difficulty of swallowing), muscle wasting and atrophy (loss of muscle tissue and strength), and atrial fibrillation (irregular and often very rapid heart rhythm). Record review of Resident #27's quarterly MDS assessment, dated 01/03/2025, revealed the resident's BIMS was 15 out of 15 which indicated the resident's cognition was intact, and the resident required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for most activities such as sit to stand and chair-to-bed transfer. Record review of Resident #27's care plan, dated 12/15/2023, revealed the resident had a pacemaker related to atrial fibrillation and for intervention - monitor/document/report to medical doctor any sign and symptom of altered cardiac output or pacemaker malfunction, and lower than baselined blood pressure. Observation on 02/20/2025 at 8:42 a.m. revealed Medication Aide-I took a resident's blood pressure and then moved to Resident #27's room. Further observation on 02/20/2025 at 09:16 a.m. revealed Medication Aide-I entered Resident #27's room and measured the resident's blood pressure without cleaning the blood pressure cuff of the monitor machine that the medication aide used before going to Resident #27's room. The Medication Aide then gave a medication to Resident #27 for atrial fibrillation. Interview on 02/20/2025 at 9:26 a.m. Medication Aide-I stated she used the same blood pressure cuff of the monitor machine without cleaning it when she measured Resident #27's blood pressure. Further interview, the Medication Aide said she forgot it and she should have cleaned the blood pressure cuff of the machine before using it to Resident #27 to prevent possible infection. Interview on 02/20/2025 at 4:00 p.m. the DON stated Medication Aide-I should have cleaned the blood pressure cuff of the machine before using it to Resident #27 to prevent possible infection. 4. Observation and interview on 02/18/25 at 03:20 PM of the W 600 hall shower room revealed a wet washcloth with a brown substance on it. Interview with ADON L revealed the substance on the washcloth was feces. She stated a CNA probably left the washcloth after showering a resident. She applied a plastic glove, took the washcloth, turned it over and there was a clump of feces on it. ADON L stated the CNA should have rinsed the washcloth, put it in a plastic bag and put it in the soiled linen barrel. ADON L stated the CNA should have sanitized the shower stall including the floor to avoid infection transmission. Telephone interview on 02/21/25 at 12:20 PM with the DON revealed aides should remove a washcloth with feces or a used towel in general from the shower room and placed it in the soiled linen barrel. He stated the aide should sanitize the floor and stall after showering residents to prevent the transmission of infections. He stated nursing staff should round and address any concerns with the aides. He stated the ADONs and other administrative staff would also make rounds making spot checks and should address any concerns with the charge nurses. Record review of the facility policy, titled Infection Control, revised on 10/2022, revealed Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient, Enhanced Barrier Protection (EBP): expand the use of personal protective equipment and refer to the use of gown and gloves during high-contact resident care activities, such as tube feeding, and Hand Hygiene - Use an alcohol-based hand rub for the following situations: . Before performing any non-surgical invasive procedures and after removing gloves. Review of facility policy, Infection Prevention and Control Program, Infection Prevention and Control Program - Linens, revised 9/2022, read in relevant part I. Policy Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. II. Procedure: I. Soiled laundry and bedding (e.g., personal clothing, uniforms, scrub suits, gowns, bedsheets, blankets, towels, etc.) contaminated with blood or other potentially infectious materials must be handled as little as possible and with a minimum of agitation. 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers. 4. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). 5. Environmental services staff or designee will bag contaminated laundry that is to be picked up and processed. 6. Environmental services and nursing staff will place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags, or leak-proof bags or containers.

39049 Based on observations, interviews, and record review, the facility failed to ensure the resident received care and services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk; provided maintenance services necessary to maintain an orderly, and comfortable interior; provide adequate and comfortable lighting levels in all areas; for 2 of 2 shower rooms (600 hall shower on E and W side), maintained shower free of saftery hazards for 1 of 2 Showers (600 Hall Shower), and 1 of 1 Resident's room (Resident #68) reviewed for safety hazards. 1. The water temperature in the 600 E shower room reached 95.5 degrees and the water temperature in the W shower room reached 97.1 degrees. The safe water temperature range should be 100 to 110 degrees. 2. There was a long hole on a wall around an electrical outlet beside Resident #68's bed. 3. There was broken tiles in the 600 E shower room for at least a couple of months. These failures could place residents at risk of living in an uncomfortable and unsafe environment; exposing them to possible electrical hazards and resulting in decreased feelings of self-worth, and a diminished quality of life. The findings included: 1. Observation and interview on 02/18/25 at 02:17 PM revealed Resident ##121 was sitting in bed. He expressed being upset because he could not take a shower. He stated there was no hot water. He stated he did not get a shower the week before on Thursday (2/13/25), Saturday (2/15/25) and then again today. Resident #121 stated nursing staff offered him a bed bath on Saturday but he preferred a hot shower. He stated it had been an on-going issue for at least a couple of weeks. Observation and interview on 02/18/25 at 03:10 PM revealed ADON L running the hot water in the 600 E shower stall. The ADON ran the hot water several minutes. The ADON stated the water temperature felt luke warm to the hand. Observation and interview on 2/18/25 at 3:20 with ADON L in the 600 W shower room revealed she ran the hot water in the shower stall for several minutes. She stated the water temperature was luke warm to the hand. ADON L stated she knew some of the residents liked he water hotter during showers. Interview on 2/18/25 at 3:35 PM with the ADM revealed they had a problem with the hot water a couple of months ago and he had a plumbing company come out. They replaced the mixing valve on the water heater which serviced the 600 hallway. He stated this was the result after Resident #121 complained the water temperature was cold in the shower. Observation and interview on 2/18/25 at 4:20 PM revealed the ADM running the hot water in the 600 E shower stall. He collected water in a plastic cup and took the temperature with a thermometer. He ran the hot water for about 3 to 5 minutes. The ADM stated the temperature was 94.3. The ADM then took the temperature of the water at the sink. He stated the temperature was 95.5. The ADM stated he was not sure what the safe range was for the water temperature. Observation and interview on 2/18/25 at 4:27 PM revealed the ADM and MS M from a sister facility took the temperature of the water in the 600 W shower stall collecting the water in plastic cup. The MS stated the water temperature was 96. He then took the temperature at the sink and stated it was 97.1. The MS stated the safe range for the water temp in Texas was 100 to 110 degrees. Interview on 02/20/25 at 4:35 PM with CNA J revealed she worked on the 600 hall regularly. She stated Resident #121, Resident #129, and Resident #130 had complained about cold water in the shower. CNA J stated they liked the water very hot water during showers and refused to shower when the water was luke warm. She stated the water had been luke warm off and on for about 4 to 6 weeks after the MS made some adjustments on the water heater. CNA J stated administrative staff stated they adjusted the temperature in order to stay in compliance with city or state guidelines. She stated about the only time the water was very hot was first thing in the morning otherwise it was luke warm especially after providing multiple showers. CNA J stated she would offer Resident #121, #129 and #130 a shower in the morning. Telephone interview on 02/21/25 at 10:36 AM with the facility MS revealed a plumbing company replaced the mixing valve on the water heater which serviced the 600 hall about a couple of months ago. He stated he set the temperature at 110 degrees. He stated last week there was a complaint about cold water in the shower, so he adjusted it and set it just a bit higher to avoid scalding water temperatures. The MS stated they checked water temperatures weekly and usually about mid-day. He stated the water temperatures had been within safe range which was 100 to 110 degrees. 2. Record review of Resident #68's face sheet, dated 02/21/2025, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] with cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), difficulty in walking, hypertension (high blood pressure), muscle weakness, and atherosclerotic heart disease of coronary artery without angina pectoris (involves plaque buildup in artery walls). Record review of Resident #68's quarterly MDS, dated [DATE], revealed Resident #68's BIMS score was 14 out of 15 that indicated the resident's cognition was intact, and the resident was independent (Residents completes the activity by themselves with no assistance from a helper) to sit to lying, lying to sitting on side of bed, and chair-to-bed transfer, but required substantial/maximal assistance (Helper does more than half the effort) to toilet transfer. Observation on 02/18/2025 at 10:04 a.m. revealed there was an electronic outlet to the wall beside Resident #68's bed, and around the electronic outlet, there was a hole (length was about 12 cm, and the width was about 8 cm). Interview on 02/18/2025 at 11:20 a.m. with Resident #68 stated that the resident did not know the electronic outlet had a hole and did not use the electronic outlet. However, the resident stated it should have been fixed to prevent possible danger. Interview on 02/18/2025 at 11:12 a.m. with LVN-C stated there was a long hole to a wall around an electric outlet beside Resident #68's bed, nobody reported it to nurses, and it might cause electronic danger if Resident #68 touched the hole or put something inside the hole. In an interview on 02/21/2025 at 12:14 p.m. the Administrator said there was a long hole to a wall around an electric outlet beside Resident #68's bed, the facility did not know about the hole, and it was not good and not safe. The facility maintenance already left the building due to private reason, so the Administrator said he would contact the maintenance staff and let them fix it. Record review of the facility policy, titled Quality of Life - Safety, Resident, revised on 09/2016, revealed It is the policy of this facility to create a safe environment for the resident. 4. Avoid leaving in the resident's room any medication or equipment that might cause harm. It is the policy of this facility to ensure the resident environment remains as free of accident hazards as possible. PROCEDURES: 1. Let the hot water run from the faucet for 3 to 5 min. 2. Insert the stem into the stream of running water, so that the sensor is fully immersed. Some thermometer probes have a sensor in the tip and others have it from tip up to about 2 inches up the probe. The temperature should register in about IO to 15 seconds. 3. Test the water at various locations throughout your facility. with these areas being of primary focus a. Patient rooms, common areas, shower rooms, and Nurses station water temperatures are between > 100 and <110 Fahrenheit. 3. Observation and interview on 02/20/25 at 4:35 PM with CNA J while in the 600 E hall shower room revealed broken tiles on the bottom on both sides of the door enclosure next to the shower stall. CNA J stated she had seen the broken tiles months ago and stated it could cause skin tears or more serious skin injuries. She stated she had not reported it to maintenance but understood she could enter a work order for the MS on an electronic communication program so he would be aware and address the issue. CNA J stated she had not said anything to her nurse either but could have done that too. She stated it was important to report the broken tiles to ensure residents were not injured. Observation and interview on 2/20/25 at 4:55 PM with LVN K on the 600 E hall shower room revealed she knew of the broken tiles in the shower room along the door frame of the sitting area next to the shower stall. She stated she had seen the broken tiles weeks ago when making rounds and when she entered the shower room. LVN K stated residents could sustain skin tears or more serious skin injuries if they rubbed up against the broken tiles. LVN K stated she should have reported it to the MS but knew the MS made his own rounds. She stated she believed the MS knew about the problem. Telephone interview on 2/20/25 on 2/21/25 at 10:36 AM with the MS revealed he and his assistant completed safety checks of the building weekly including the shower rooms. He stated he noticed the broken tiles in the 600 E shower room some weeks back, but understood it would be addressed during the facility refresh. He stated a contractor would be making some renovations and the shower rooms were included in the plan. The MS stated he did not consider the safety risks at the time but stated it could cause skin cuts and it was not the place you want to get a cut because of infection control. He stated staff had not sent a work order through the facility computer program but stated he knew about the broken tiles and should have addressed it right away. Review of facility Policy and Procedure, Facility Maintenance, revised on 5/2022, read in relevant part: It is the policy of this facility to establish procedures for routine and non-routine care of the facility /building to ensure that the facility remains in good working order for resident and staff safety. 1. The facility utilizes the [name] program that tracks and maintains documentation for Preventative Maintenance and Regulator Tasks. Work Orders: 1. All work order requests must be in the form of work orders, not verbal (unless emergency situations). 2. The facility uses electronic work orders through [name].

Based on record reviews and interviews, the facility failed to ensure each PASRR Level 1 Screening done for each resident was correct for mental illness for 1 of 2 residents'(Resident #10) PASRRs reviewed, in that: Resident #10 had a PASRR Level 1 screening that did not indicate that she had a mental illness with a diagnosis of bipolar disorder and, the facility did not have Resident #10 screened again for possible services. This failure could cause the residents not to receive services needed to maintain the highest functional ability for their quality of life. The findings included: Record review of Resident # 10's face sheet dated 02/20/2025revealed an [AGE] year old female admitted to the facility on [DATE] with diagnoses that included: CHF (congestive heart failure- a condition which the heart does not pump blood as well as it should), anxiety disorder, dementia, and bipolar disorder. Record review on of Resident # 10's Care Plan dated 11/06/2024 revealed Resident #10 was care planned for bipolar disorder with the use of an anti-psychotic medication. Record review on of Resident # 10's physician orders dated 11/14/2024 revealed the resident had an order for risperdal 1mg(milligram) at bedtime for mania. Record review on 2/20/2025 of Resident # 10's Quarterly MDS dated [DATE] revealed Resident # 10 had a BIMS score of 15 which was indicative of her cognition was intact. During an interview on 2/21/2025 at 9:30AM the SW said she started at the facility at the end of November 2024. She said for new admissions, the AC would usually helped and she was not sure if residents with mental illness were screened for PASRR services. The SW said she would ask the Administrator for an answer for residents with a mental illness diagnosis. During an interview on 2/21/2025 at 9:40AM the Administrator said he was not sure of the answer for residents with a mental illness diagnosis on whether they should be screened for PASRR services. He said the MDS Coordinator, and the AC (Admissions Coordinator) could be of better help for the answer. During an interview on 2/21/2025 at 10:25AM the AC said when the facility received a PASRR from the hospital, the resident would be referred for services if it was positive and it would be uploaded in Point Click Care with the resident's records but was not sure if residents with mental illness should be screened for a Level II. She said the process would be when a positive PASRR was received it would be sent to the Social Worker to refer to the agency for Level II screening. The AC said they did not check to see if PASRR was correct and compare to the admitting resident's diagnosis to ensure if they were coded correctly. The DBD said unless a resident would be admitted from the community, that would be when the facility would do a PASRR Level 1 screening. The AC said they would now initiate the step of verifying the accuracy of the PASRRs for new admissions to ensure the residents received the services they need if eligible. During an interview on 2/21/2025 at 11:00AM the SW said PASRRs should be done correctly to ensure residents who were positive received the services they need. She said she realized now that the PASRRs on admission should be checked for accuracy and if done incorrectly, they need to be done correctly in correlation to the residents' diagnosis. Facility policy titled Resident Assessment and Associated Process dated 12/2023 stated: It is the policy of this facility that residents will be assessed and the finding documented in their clinical health record. Under Comprehensive Assessment stated: 5. Assessment information will be used to develop, review and revise the resident's comprehensive care plan. When applicable, recommendations from the pre-admission screening and resident review (PASRR) evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on interview and record review the facility failed to, based on the comprehensive assessment of a resident, ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care . 1. The facility staff administered Resident #1's digoxin (medication used to manage and treat heart failure and certain abnormal heart rhythms) without documenting the ordered blood pressure and pulse per the physician ordered parameters from [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE] (23 days) and failed to hold the medication as ordered per parameters on [DATE] and [DATE] . 2. The facility staff failed to administer Resident #1's midodrine (medication used to raise abnormally low blood pressure) as ordered to be given PRN every 8 hours for SBP<100 on [DATE], [DATE], [DATE], [DATE], and [DATE] (5 instances) when the resident's SBP was below 100 . 3. The facility staff failed to assess Resident #1 for a change of condition related to continued complaints of nausea on [DATE], [DATE] and [DATE]. Resident #1 was discharged to the hospital by EMS on [DATE] and expired in the emergency room . An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:51 p.m While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facilities need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk of a critically low pulse and blood pressures, inadequate blood flow, missed signs and symptoms of illness, hospitalization and death. The findings were: 1. Closed record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteomyelitis, unspecified (a serious infection of the bone that can be either acute or chronic), unspecified atrial fibrillation (an irregular and often rapid heart rhythm), atherosclerotic heart disease of native coronary artery without angina pectoris (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of the coronary artery without chest pain or discomfort), and acute kidney failure (sudden or rapid failure of the kidneys being unable to filter waste products from the blood). The resident was discharged to the hospital by EMS on [DATE]. Closed record review of Resident #1's care plan reflected a focus, initiated on [DATE] , for Digoxin therapy related to Heart Failure with an intervention to report to the physician any anorexia, nausea, vomiting, diarrhea, or visual disturbances. Another focus initiated on [DATE] for an indwelling foley catheter with multiple interventions included to monitor, record, and report to the MD no urine output and an increased pulse. Closed record review of Resident #1's admission MDS assessment dated [DATE] indicated the resident had a BIMS ,d+[DATE] indicating the resident had moderate cognitive impairment, had a foley catheter, and used a wheelchair. Closed record review of Resident #1's physician orders reflected an order with a start date of [DATE] for digoxin 0.0625 mg once daily for heart rate, hold for SBP <100 or heart rate < 60. (the medication was scheduled for the administration time of 7:00 a.m.) Closed record review of Resident #1's EMAR for February 2024 reflected Resident #1's digoxin was documented as administered by CMA C on [DATE] to [DATE], [DATE] to [DATE] and [DATE] to [DATE] without documentation of the blood pressure or pulse readings. It was documented as administered by CMA D on [DATE] without documentation of the blood pressure or pulse readings. Closed record review of Resident #1's EMAR for [DATE] reflected Resident #1's digoxin was documented as administered by CMA C on [DATE], [DATE] to [DATE] and [DATE] to [DATE] without documentation of the blood pressure or pulse readings. Closed record review of Resident #1's EHR under the vital signs tab, reflected there were 4 blood pressure and 3 pulse readings from [DATE] to [DATE]. The documentation was as follows: on [DATE] at 8:06 a.m. B/P- ,d+[DATE], P-96. On [DATE] at 1:53 p.m. B/P- ,d+[DATE] with no pulse documented. On [DATE] at 8:18 a.m. B/P- ,d+[DATE], P-88. Closed record review of Resident #1's EHR under the vital signs tab, reflected there were 2 blood pressure and 1 pulse reading for [DATE]. The documentation was on [DATE] at 8:27 p.m. B/P- ,d+[DATE], P- 97. On [DATE] at 3:30 p.m. B/P-,d+[DATE] with no pulse documented. 2. Closed record review of Resident #1's physician orders reflected an order with a start date of [DATE] for midodrine 2.5mg every 8 hours as needed for low BP, give if SBP<100. Closed record review of Resident #1's EMAR for February 2024 reflected midodrine spaces for administration and blood pressure documentation were blank for the entire month of February. Closed record review of Resident #1's EMAR for [DATE] reflected midodrine spaces for administration and blood pressure documentation were blank for [DATE] to [DATE]. Closed record review of Resident #1's EMAR for February 2024 reflected on [DATE] digoxin was held for B/P- ,d+[DATE] and indicated the midodrine should have been administered per ordered parameters. Closed record review of Resident #1's EHR under the vital signs tab, reflected midodrine should have been administered per ordered parameters on [DATE] at 8:06 a.m. B/P- ,d+[DATE], [DATE] at 8:18 a.m. B/P- ,d+[DATE], [DATE] at 8:27 p.m. B/P- ,d+[DATE], and [DATE] at 3:30 p.m. B/P-,d+[DATE]. 3. Closed record review of Resident #1's physician orders reflected an order with a start date of [DATE] for zofran (anti-nausea medication) 4mg tablet every 6 hours PRN for nausea or vomiting. Closed record review of Resident #1's EMAR for [DATE] reflected the resident was administered zofran 4mg tab on [DATE] at 6:41 a.m. by RN B, on [DATE] at 6:48 p.m. by LVN A and on [DATE] at 8:14 a.m. by RN B. Closed record review of Resident #1's EMAR linked progress notes for Zofran 4mg tab reflected a note, dated [DATE], at 7:36 p.m., indicated the administered dose at 6:41 a.m. was effective with no other documentation or assessment between these two times regarding nausea. A linked note, dated [DATE] at 9:54 p.m., indicated the dose administered at 6:48 p.m. was effective. A linked note, dated [DATE] at 10:00 a.m., indicated the dose administered at 8:14 a.m. was ineffective. Closed record review of Resident #1's progress notes reflected a note, dated [DATE] at 9:59 p.m., indicated the resident complained of pain, muscle spasms, and nausea and he was medicated for pain and nausea and both were effective and the resident was resting comfortably, eyes closed, respirations even and unlabored. Closed record review of Resident #1's Physician orders reflected an order with a start date of [DATE] at 10:15 a.m. for Zofran 8mg tablet every 6 hours PRN for nausea and vomiting. Closed record review of Resident #1's EMAR for [DATE] reflected the resident was administered zofran 8mg tab on [DATE] at 11:01 a.m. by RN B. Closed record review of Resident #1's EMAR linked progress reflected a note for Zofran 8mg tab, dated [DATE] at 12:52 p.m., and indicated the dose administered at 11:01 a.m. was effective. Closed record review of Resident #1's EHR, under assessments, reflected an SBAR communication form, dated [DATE]. The Situation section was not filled out, the resident evaluation was not filled out, B/P- ,d+[DATE], P-97, R-20, O2 Sat 98% with no date or time taken. Closed record review of Resident #1's EHR, under assessments, reflected a Nursing Home to Hospital Transfer Form, dated [DATE], with blood pressure and pulse documented as B/P- ,d+[DATE], P- 97 and under reason for transfer Urinary Incontinence was listed. Closed record review of Resident #1's progress notes reflected a change in condition note by an unknown nurse, dated [DATE] at 3:25 p.m., indicated to refer to the change in condition form for the full assessment. The blood pressure in the note was B/P ,d+[DATE], P-97 and the date and time next to it were [DATE] at 8:27 p.m. The pulse in the note had the date and time taken as [DATE] 8:28 p.m. The temperature of 97.1 Fahrenheit and O2 sat of 98% had the date and time of [DATE] at 11:17p.m. Closed record review of Resident #1's progress notes reflected a note by an unknown nurse, dated [DATE] at 1:08 p.m., indicated the foley catheter was not draining and it was replaced. The resident having bladder spasms. Will continue to monitor for output. Closed record review of Resident #1's progress notes reflected a note by an unknown nurse, dated [DATE] at 9:19 p.m., indicated at approximately 2:30 p.m. the foley catheter was not draining, his abdomen was hard, and the resident was having spasms when palpating around the bladder. The resident complained of pain but was unable to focus or tell where pain was .Skin clammy, grayish, and pale. Lethargic and unable to answer questions. The NP was notified and 911 called and the resident left the facility at 1:20 p.m. Closed record review of Resident #1's EMAR for February 2024 reflected Zofran 4mg tablet PRN nausea and vomiting was not administered for the entire month (indicating the nausea was a new change for the resident in March). Closed record review of Resident #1's Physical Therapy encounter notes, dated [DATE] at 1:58 p.m., reflected under response to session was documented .patient in a lot of pain today and has been asking for increased pain meds since last night, nursing had to change catheter and is still not voiding, informed nursing and requesting he be sent to the hospital due to patient not looking good, in that he was ashy, clammy, and out of it. Closed record review of Resident #1's Occupational Therapy encounter notes, dated [DATE] at 2:19 p.m., reflected under response to treatment.Patient tolerated therapy but was not well. Patient was sick at his stomach, clammy and ash color. Patient was drooling while laying on his side with eyes halfway open. Nursing made aware of situation and after further review patient is being sent out. Record review of EMS run report for Resident #1, dated [DATE] at 3:04 p.m., reflected .Upon arrival a nurse greets us and states the patient hasn't produced urine in several days and they are concerned. When EMS arrived at the resident's bedside the resident was Alert and oriented to person, place, time, and situation and was giving EMS his extensive history and complaining of nausea and pain to his sacrum area but denied any chest pain, shortness of breath, headache, blurred vision, dizziness, abdominal pain, or any other pain or injury. The resident was transported without change or incident. Under primary complaint documented nausea and not producing urine and had not eaten in 3 days. Blood pressure and pulse readings were documented at 3:15 p.m. B/P- ,d+[DATE], P-76, and at 3:17 p.m. B/P-,d+[DATE], P-82, at 3:22 p.m. B/P- ,d+[DATE], P- 79, at 3:27 p.m. B/P- ,d+[DATE], P-74 and at 3:40 p.m. B/P- ,d+[DATE], P-71. Record review of the facility pharmacy review dated [DATE], by PH indicated a review was completed on [DATE] and [DATE] and included Resident #1. The pharmacy review indicated Medication regimen reviewed. No recommendations. Record review of Resident #1's emergency room record dated [DATE] reflected arrival vital signs at 4:00 p.m. included B/P- ,d+[DATE], P- 66, in moderate distress, with pale skin and conjunctiva. The resident was moved to the resuscitation room and began to deteriorate rapidly. The resident's bloodwork showed critical levels with the sodium level low at 120, his potassium level was high at 6.6, and 7.5 readings, white blood cell count was 25.6, and his cardiac treponin level was at 14.65. The resident's blood pressure remained low despite treatment. The resident stopped breathing and had no pulse and CPR was started at 5:25 p.m. and was unsuccesful, efforts ceased at 6:06 p.m., the resident expired. Under primary impression Hyperkalemia (high potassium level) and under additional impressions was NSTEMI (Non-ST Elevated Myocardial Infarction), Hyponatremia (low sodium level), Urinary tract infection with hematuria, acute kidney failure, cardiac arrest, and death. Further review revealed the documentation reflected the resident was thought to have urosepsis (serious infection caused by bacteria from the urinary tract invading the bloodstream) that progressed to multiorgan failure. And . he was seriously ill when he arrived and we were unable to resuscitate him due to the severity of his illness. Other possibilities in the differential diagnoss are MI (Myocardial Infaction), acute kidney injury, congestive heart failure, aortic dissection. Review of Digoxin at https://www.drugguide.com/ddo/view/[NAME]-Drug-Guide/51218/all/digoxin#:~:text=Hold%20dose%20and%20notify%20health,rhythm%2C%20or%20quality%20of%20pulse.Hold dose and notify health care professional if pulse rate is <60 bpm in an adult Notify health care professional promptly of any significant changes in rate, rhythm, or quality of pulse. In an interview on [DATE] at 3:15 p.m. the DON stated he completed in-services with staff as soon as the issue with Resident #1's blood pressure parameters and change of condition was identified and the facility was working on a performance improvement plan. The DON stated somehow Resident #1's digoxin orders were changed but when they were changed the second time, the vital sign entry was dropped somehow from the MAR and the DON was not sure how and was still investigating. The DON stated he was still working on further interventions but had already started in-services on change of condition and other training for staff and additionally did a 1 on 1 in-service with LVN A and RN B who cared for Resident #1 on [DATE]. The DON provided copies of what was completed so far. The DON stated it was still in process, but in-services started on [DATE]. In an interview on [DATE] at 4:15p.m., the MD stated Resident #1 had an unfortunate event of rapid onset sepsis and his dose of digoxin was negligible and had no bearing on the events that sent the resident to the hospital. The MD stated the resident had significant comorbidities that contributed to his illness and being sent to the hospital. When asked what his expectation was for taking blood pressure and pulse readings prior to administration of midodrine and or digoxin medications with ordered parameters, the MD stated in an ideal world, in an ideal situation it would be nice but it did not contribute to the resident going to the hospital. When asked if the expectation were that vital signs were taken and documented as ordered the MD stated again in an ideal situation it would be nice. The MD stated there was no harm to the resident from the vital signs not being documented and again stated this was an unfortunate rapid event brought on by the resident's significant medical and surgical history. In an interview on [DATE] at 5:10 p.m., RN B stated Resident #1 was alert and oriented and complained of nausea, was medicated as ordered and it was effective. It was not until [DATE] that it was not effective but she contacted the provider and got the order to increase the Zofran to 8mg. RN B stated she thought it was effective at first because the resident was sleeping but someone woke the resident up shortly after. RN B stated the resident told her he thought the foley catheter needed to be changed again because it was not draining as much, and RN B replaced the foley catheter. RN B stated the same thing happened with the foley catheter previously and the resident was complaining of bladder spasms so she was waiting to see if the foley catheter would start draining better when his bladder spasms were over but he was being monitored and the resident was the same and at his baseline. RN B stated the resident's family member was at the bedside as well and the resident denied any pain to his bladder area and had just reported bladder spasms. RN B stated she passed on the information in report and her and LVN A looked at the foley catheter during shift change report. RN B stated there was a small amount of urine in the tubing and bag but not more than 100ml. RN B stated in general if a CNA or someone else took vital signs it was given to the nurse on paper. In an interview on [DATE] at 6:00 p.m., LVN A stated Resident #1 had 600ml of urine output that was clear and orange in color with no sediment in the tubing or bag the night before ([DATE]) the resident was sent to the hospital. LVN A stated the resident was alert and oriented to person, place, and time. The resident received therapy for his sacral wound when she walked into the room and stated she would come back when therapy was finished. LVN A stated when the resident did not have any urine output, she bladder scanned the resident and it read there was 0 ml's of urine in the bladder. LVN A stated she explained to the resident and his family member Resident #1 needed to go to the hospital for higher acuity care due to not having any urine output and the resident and his family member were against the resident going to the hospital, but she continued to explain it was serious. LVN A stated the resident and his family member did not want to go to a government hospital as the resident had a bad experience in one about a year ago. LVN A stated the resident and his family member agreed to Resident #1 going to the hospital but not by EMS and agreed to go by regular transport ambulance. LVN A stated she contacted the facility contracted ambulance company and they told her it would be 1.5 hours before they could get there. LVN A stated she immediately hung up and called 911 and was texting the NP at the same time. LVN A stated she noted a color change to the resident just prior to calling 911. LVN A stated she attempted with 3 different blood pressure machines to get a blood pressure but was having difficulty and was not sure the ,d+[DATE] was correct but EMS arrived by that time and took over assessing the resident. LVN A stated Resident #1 was alert and at his baseline the entire time and Resident #1 told her [LVN A], you can fix this, I know you can and LVN A stated she continued to tell the resident he required higher level care. LVN A stated when EMS arrived the resident was alert and oriented to person, place and time and remained at his baseline when he was transferred to the hospital. LVN A stated she wrote notes down on a piece of paper she carried with her during her shift but did not have the sheet anymore and shredded them prior to leaving but that was where the vital signs were usually written until transferred to the computer especially if another staff member had taken a blood pressure or pulse or if she was really busy . LVN A stated she stayed late to document but her assessment and interventions such as bladder scanning might not have been documented because she was busy and ran out of time. LVN A stated other than the low blood pressure at the time of the resident's transfer she was unsure of any low blood pressure issues and would have been notified by the medication aide giving the digoxin but that would have been most likely on paper if it was low and would have been taken again to confirm. In An Attempted Telephone Interview On [DATE] at 7:13 p.m., CMA C was called with no answer. A message was left to return call. In an interview on [DATE] at 3:10 p.m., the PH stated she thought it was between visits the parameters were dropped. The PH stated he always made sure the BP meds or antiarrhythmics had the correct parameters. The PH didn't make a recommendation for his parameters which meant when he reviewed the EMARs it would have had them. There's a digoxin order for February, it has parameters. The midodrine was PRN and it said to give if SBP was less than 100. In February, the last time the PH did a review of the orders and MARS the dig had parameters and the midodrine was PRN and had parameters. The dig order was changed in March, the new order, the digoxin order had parameters until the resident was discharged and the midodrine was still PRN if SBP was less than 100. If the hold parameters were missing, that was a recommendation he always made. These two particular meds should always have parameters. He would have recommended parameters for digoxin HR less than 60 to hold and midodrine for scheduled it depended on the resident and MD orders. For digoxin across the board, it's held for less than 60. Sometimes the MDs would have different parameters (patient specific based on their current condition), but if there were no hold parameters, the PH always recommended adding hold parameters. Digoxin - if HR was less than 60 it could possibly lower the heart rate more. Midodrine - it should only be given if the B/P was low if the B/P was low and it wasn't given the B/P would most likely stay low or could go lower. It won't necessarily go lower, but it won't raise it to normal levels. Record review of staff in-service training provided by the DON reflected a Process improvement for residents, dated [DATE], and included add urine output monitoring to all residents with urinary catheters, Audit completed [DATE]. Inservice staff on new output monitoring process. Daily vitals for VA (Veterans Administration) residents, Audit completed [DATE]. Audit all residents on digoxin for heart rate parameters complete [DATE]. In-service nurses on heart rate parameters. Audit of B/P parameters on all residents complete [DATE]. Audit of B/P parameters on all residents complete [DATE]. Inservice nurses on B/P parameters. In-service LVN A and RN B on acute change of condition and resident assessment. IDT meeting to evaluate process after resident refuses treatment for infection. Plan twice a week minute meetings with nurse to review body system specific assessments (Tuesday/Thursday). Plan to start mock rapid response drills with nurses, mock crash cart equipment obtain and teaching mannequin obtained, will begin collecting written material [DATE] with goal to begin mock codes by [DATE]st. With this document were signed staff training attendance sheets for digoxin heart rate parameters and all B/P medications must have B/P and heart rate parameters dated [DATE] and signed by 17 staff members. Signed staff training dated [DATE] for urinary catheter output monitoring signed by 43 staff members. Signed staff training dated [DATE] for LVN A and LVN B for acute change of condition and resident assessments signed by both LVN A and LVN B. Signed staff training dated [DATE] which included care profile, Kardex, every shift charting, output monitoring, heart rate and B/P parameters and signed by 49 staff members. Record review of the facility's policy on medication administration, dated ,d+[DATE], indicated the policy: .It is the policy of this facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant . 2. Medications must be given in accordance with the resident's service plan. 3. Medications must be administered in accordance with the written orders of the attending physician. Record review of the facility policy on significant change of condition response, revised on ,d+[DATE], indicated It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care . 1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware. Examples would be the following (but not limited to): Change or a trending change in vital signs, to include temperature, pulse, blood pressure, heart rate, and oxygen saturation . Change in ability to eat or drink . changes in weight or intake . New complaints of pain or worsening pain . Change in output (bowel and bladder) including amount, color . 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3. The resident will then be placed on the 24-hour report and nursing will provide no less than 3 days of observation, documentation, and response to any interventions This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator and DON were notified. The Administrator was provided with the IJ template on [DATE] at 8:51 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 10:35 a.m. [Facility Name] Plan of Removal Version 2 F684: [DATE] Per the information provided in the IJ Template given on [DATE], the facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice for quality of care. 1. The medical director was notified at 10:11 pm on [DATE]. The pharmacist was notified at 10:13 pm on [DATE]. 2. Resident #1 is no longer in the facility. Resident #1 was discharged to the hospital on [DATE] at 3:20 pm. 3. 100% audit on residents who require medications with parameters was completed by [DATE] by DON/designee. 4. New orders, Change of Condition progress notes, and 24-hour report for any parameter triggers of medications will be reviewed daily by DON or designee. Results of these audits will be taken to monthly QAPI for tracking, trending, and recommendations. 5. In-servicing began on [DATE] for Licensed nurses and CMA's to include anti-arrythmias and hypotensive meds with parameters and will be completed by [DATE]. Any employee not in facility will receive in service via phone, any employee who has not received in-service will not be allowed to work until in-service has been received. In-servicing completed by DON/designee. The staffing roster will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. No nursing or CMA staff will work the floor prior to completing the required trainings. 6. Education to Nursing staff on COC policy and completion of COC's began on [DATE] and will be completed by [DATE]. Any employee not in facility will receive in service via phone, any employee who has not received in-service will not be allowed to work until in-service has been received. In-services completed by DON/designee. The staffing roster will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. No nursing or CMA staff will work the floor prior to completing the required trainings. 7. In-service charge nurses and nurse managers on utilization of the dashboard to assess for parameter alerts requiring follow up while on duty by DON/designee beginning [DATE] and will be completed [DATE]. Any employee not in facility will receive in service via phone, any employee who has not received in-service will not be allowed to work until in-service has been received. The staffing roster will be assessed daily prior to each shift by the ED/DON or designee to ensure compliance. No nursing or CMA staff will work the floor prior to completing the required trainings. 8. Medical director or designee to review all anti-arrythmia and hypotensive meds with parameters by [DATE]. 9. Incorporate findings and improvements into the facilities QAPI program to ensure sustained compliance and adherence to medication parameters alerts and policies monthly in QAPI for 90 days until on-going compliance confirmed. Monitoring of the POR included the following : In interviews on [DATE] starting at 7:30 p.m. with 2 CMA's, 4 CNA's, 3 LVN's, 1 RN, and LVN A all confirmed they were trained on change of condition, B/P and pulse readings, and urinary output monitoring. The CNA's and CMA's were able to describe different scenarios where the nurse would be notified and things to look for that were out of baseline for the residents. The CMA's were able to state holding medications where vital signs were outside the ordered parameters and notifying the nurse and stated digoxin always had to have a pulse before administering the medication. All licensed staff interviewed confirmed they were trained and were able to state assessments and documentation to be done and when to contact the physician. In an interview with the Medical Director on [DATE] at 3:41 p.m. the Medical Director stated he was notified of the IJ yesterday ([DATE]). In an interview with the Pharmacist on [DATE] at 5:02 p.m. the Pharmacist stated she was notified of the IJ yesterday. Record review of the electronic medical record reflected Resident #1's status as discharged [DATE]. A record review and interview with the DON on [DATE] at 1:51 p.m. revealed the DON completed an audit on [DATE] of 12 residents who required medications with parameters. A record review and interview with the DON on [DATE] at 1:51 p.m. revealed the DON reviewed new orders, change of condition progress notes and the 24-hour report on [DATE]. [DATE] Monitoring of residents with high-risk medications was completed by the DON on [DATE] and [DATE]. In an interview with the DON and Administrator on [DATE] at 1:52 a.m. revealed in-services were completed as staff arrived for work on [DATE]. Staff who were not on shift were called in to be in-serviced or in-serviced via phone. Record review of in-service materials and sign in sheets for clinical staff included 21 in person in-services and 10 via phone. Observation of a sign on the front door informing staff must receive training before returning to work. Staff interviewed on [DATE] at 2:08 p.m. to 3:34 p.m., included: RN - 1; LVN - 5; CMA - 2 . The staff confirmed they had been trained on COC, Response policy/procedure and Medication Parameters, Vital Sign Alert Follow Up, and Dashboard Utilization. Staff interviews on [DATE] included: 3 on the 6 am - 2 pm shift; 3 on 6 am - 6 pm shift; 1 on the 2 pm - 10 pm shift; and 3 on the 6 am - 10 pm. The staff interviewed confirmed they had been trained on COC, Response policy/procedure and Medication Parameters, Vital Sign Alert Follow Up, and Dashboard Utilization. There were no CMAs scheduled for the 10 pm - 6 am shift, calls to 4 LVNs on the 10 pm - 6 am shift were made, there were no answers and voicemails were left for all 4. 2 interviews with 10 pm - 6 am shift LVNs were completed at 2:46 pm and 2:50 pm on [DATE]. The staff interviewed confirmed they had been trained on COC, Response policy/procedure and Medication Parameters, Vital Sign Alert Follow Up, and Dashboard Utilization. Record review of Nurses & CMA's roster included a total of 47 clinical staff. In-service materials and sign in sheets for clinical staff included 21 in person in-services and 29 via phone, which included 4 nurses that were not included on the roster. In-service material included Significant Change of Condition, Response policy/procedure and Medication Parameters, Vital Sign Alert Follow Up, and Dashboard Utilization. A record review and interview and with the DON on [DATE] at 1:51 p.m. revealed the DON completed and documented a review with the Medical Director on [DATE] for the 12 residents who required anti-arrythmia and hypotensive medications with parameters. Record review of QAPI Agenda, dated [DATE], included the following signatures: Administrator, DON, Clinical Market Leader, Market Leader, Medical Director, ADON, Maintenance Director, Therapy Director, and MDS Nurse. An I [TRUNCATED]