Every finding on record at Lady Lake Specialty Care Center and Rehab

Number of residents sampled: Number of residents cited: [NAME], [NAME] (7) [NAME], [NAME] (45576) - FTag Initiation No Notes [NAME], [NAME] (7) [NAME], [NAME] (45576) - RESIDENT NOTE No Notes

Number of residents sampled: Number of residents cited: [NAME], [NAME] (7) [NAME], [NAME] (45576) - FTag Initiation No Notes [NAME], [NAME] (7) [NAME], [NAME] (45576) - RESIDENT NOTE No Notes

Based on interview and record review the facility failed to provide dialysis services consistent with professional standards related to the assessment of the resident's condition and monitoring for 1 (Resident #12) of 1 resident reviewed for dialysis.Findings include: Review of Resident #12's clinical record documented admission on [DATE] with diagnosis that included acute respiratory failure with hypoxia, atrial fibrillation (irregular heart rhythms), end stage renal disease (kidneys function less than 15% of normal ability) and dependence on renal dialysis. Review of Residents #12's physician orders dated 10/25/2025 read Dialysis center, Tue, Thursday, Saturday pick up time 0540am. [Dialysis center name, address and number]. Review of Resident #12's dialysis communication book contained no communication of assessment of Resident #12, no Vital signs, and no weights. There was no communication from before or after dialysis treatment and no communication from dialysis. During an interview on 12/18/2025 at 10:26 AM with interview of Administrator of Dialysis center stated, We receive hardly any communication from the facility. They [the facility] are one of the harder facilities to get a hold of or communicate with. I have to keep calling them to come and pick him up, after dialysis. We are trying to rearrange the schedule to get him in later. He was here Tuesday, and today [12/18/2025] and scheduled for Saturday, then next week will be here on Monday, Wednesday and Friday. I faxed the schedule to [ the facilities name] . He hasn't missed any. He is always in pain as you know if they take meds before they come, we just pull the medication right out with dialysis. No documentation at all from the facility. No binder nothing some other facilities will send information. We do not send any information to the facility unless they have a binder with communication or if they call and request anything. During an interview on 12/18/2025 at 10:44 AM with Staff Q, Certified Nursing Assistant (CNA) stated that they make sure that the residents are clean, have something to eat to go with them and their blanket. No, we do not do weights or vital signs. We do have restorative nursing that goes around with a clip board, and they will do weights on resident and log the weights and vital signs, but all the residents are different some just once a month some daily, but we do not weigh or take vital signs before they go to dialysis. During an interview on 12/28/2025 at 10:50 AM with Staff R, CNA stated I will make sure the resident is clean, has a lunch and blanket. No vital signs or weighs on the resident is obtained. If they have a book, we will send the book with them. During an interview on 12/28/2025 at 11:15 AM with Staff N, License Practical Nurse (LPN) Unit Manager stated that the resident is supposed to be weighed, and vital signs taken prior to leaving for dialysis and we normally send a face sheet. We do not receive anything back from dialysis. During an interview on 12/28/2025 at 1:00 PM with the Director of Nursing stated we should have communication notes from our facility with the resident assessment, vital signs and weight, in the resident's binder. We normally get treatment records from the dialysis centerReview of facilities policy and procedure titled Hemodialysis dated 6/11/2025 read It will be the policy of this facility to provide the necessary care and services to those residents receiving hemodialysis while a resident at the facility . 6. The physician and dialysis center will be alerted to resident non-compliance issues of food and fluid . 9. The facility and the Dialysis Center should maintain regular communication and should a change in condition occur before or during the dialysis treatment, the sending facility should communicate the changes in needs to the receiving facility.

Number of residents sampled: Number of residents cited: [NAME], TORREEN (115) [NAME], [NAME] (51024) - Position, Mobility Limited ROM Notes [DATE] 12:03 PM During Resident interview on [DATE] at 10;23 am, who stated she hasn't been able to walk since she became disabled in 1979- a pickup truck hit her and her husband, she was in a coma for 4 months and her husband died. During record review on [DATE] at 10:32 am, Per ADL care plan and EMR she is on Pradaxa once per day for afib and is a Hoyer lift x2 staff. Most current comprehensive and most recent quarterly dated [DATE]:MDS/CAA sectionC, BIMS 4E, No behaviors exhibited, GG, Upper and lower extremity reads no Impairment I, Diagnoses:: Disorder of urinary system, unspecified Status: Active UNSPECIFIED ATRIAL FIBRILLATION Status:AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE NEED FOR ASSISTANCE WITH PERSONAL CARE HISTORY OF FALLING SLEEP APNEA, UNSPECIFIED:TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE Status: UNSPECIFIED ASTHMA, UNCOMPLICATED : MUSCLE WEAKNESS (GENERALIZED) : CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECI FIED Status MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE VITAMIN D DEFICIENCY, UNSPECIFIED OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND AWARENESS CHRONIC PULMONARY EMBOLISM Status: DYSPHAGIA, OROPHARYNGEAL PHASE: DIVERTICULITIS OF INTESTINE, PART UNSPECIFIED, WITHOUT PERFORATION OR ABSCESS WITHOUT BLEEDING UNSPECIFIED GLAUCOMA Status: Active Onset HYPO-OSMOLALITY AND HYPONATREMIAPREDIABETES Status: GENERALIZED ANXIETY DISORDER Status: HEART FAILURE, UNSPECIFIED MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIESJ, Active Pain management as needed pain medication every 8 hours as needed O. No special treatments Physician's orders: T C.O.: PT to tx 3 x a week for 60 days which may include therapeutic exercises, therapeutic activities, NMR, gait training, manual therapy, group therapy, WC mgt, pt and caregiver education and DC planning. ordered by [NAME], [NAME] on [DATE]Apply neck brace as needed for support and to alleviate pain.as needed for weakness and pain in neck ordered by Dr. ClarkDiscontinued Cefdinir 300 mg oral capsules, 1 capsule every 12 hours for 7 days, for the treatment of a urinary tract infection (UTI) on [DATE] ordered by Dr. ClarkPatient to utilize pommel cushion in WC as needed for positioning and per patient request. Late entry for [DATE] ordered by Dr. [NAME] . Pertinent diagnosishx of recent UTI antibiotic ended [DATE]Disorder of urinary system, unspecified UNSPECIFIED ATRIAL FIBRILLATIONAGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE NEED FOR ASSISTANCE WITH PERSONAL CARE HISTORY OF FALLING SLEEP APNEA, UNSPECIFIEDTYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE Status: UNSPECIFIED ASTHMA, UNCOMPLICATED : MUSCLE WEAKNESS (GENERALIZED) : CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECI FIED Status MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE VITAMIN D DEFICIENCY, UNSPECIFIED OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND AWARENESS CHRONIC PULMONARY EMBOLISM Status: DYSPHAGIA, OROPHARYNGEAL PHASE: DIVERTICULITIS OF INTESTINE, PART UNSPECIFIED, WITHOUT PERFORATION OR ABSCESS WITHOUT BLEEDING HYPO-OSMOLALITY AND HYPONATREMIAPREDIABETES Status: GENERALIZED ANXIETY DISORDER Status: HEART FAILURE, UNSPECIFIED MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIESROM Care plan:FOCUSMs. [NAME] has potential for pain r/t History of Arthritis with joint pain, Neuropathic pain, Ms. [NAME] is at risk for falls r/t impaired mobility and weakness Ms. [NAME]/responsible party wishes to remain in facility LTC per physician recommendations.GOALS: Resident will not experience a decline in overall function related to pain through next review date. Resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions through next review date. INTERVENTIONS: * Coordinate pain management with Hospice PRNAdminister and monitor for effectiveness and for possible side effects from routine and/or PRN pain medications (see MAR/physician orders) Educate resident/family about comfort measures, analgesic medications, and discuss fears/concerns regarding pain, comfort, and disease process PRNMonitor & report to nurse: Signs and symptoms of pain, Worsening of painNotify the resident's physician if they do not state /demonstrate relief or reduction of pain with current pain management regime CARE PLAN: Ms. [NAME] has potential for injury and/or pathological fracture r/t Osteoporosis Date Initiated: [DATE] Revision on: [DATE] GOAL The resident will remain free of avoidable injuries or complications related to osteoporosis through review date Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTION Initiated: [DATE] LPN RN Monitor/document for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. (If resident has a care plan for falls, refer to this). Date Initiated: [DATE] LPN RN Monitor/document/report PRN s/sx or complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis (dowagers hump, thoracic curve), Pain, especially back CARE PLAN: [NAME] has a self care deficit with dressing, grooming, bathing r/t: impaired mobility and balance, weakness. Date Initiated: [DATE] Revision on: [DATE] GOAL Resident will maintain current level of ADL functioning thru the next review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Resident will have clean, neat appearance daily thru the next review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS Assist with nail shaping, keep nails short and clean Date Initiated: [DATE] CNA Nursing Hoyer with 2 staff assist for transfers Date Initiated: [DATE] Nursing Keep Phone with in reach at all times while in room. Brother calls at 1600 every day Date Initiated: [DATE] All may go LOA with responsible party Date Initiated: [DATE] All Pommel cushion in wheelchair for positioning as needed. Date Initiated: [DATE] All Administer medications as ordered; observe for SEs and effectiveness Date Initiated: [DATE] Nursing Gather and set up supplies for cares Cue/encourage resident to participate in ADL tasks Date Initiated: [DATE] CNA Allow resident ample time to attempt/complete ADL tasks before intervening Date Initiated: [DATE] CNA Encourage/remind the resident to ask for assistanceInitiated: [DATE] CNA Encourage/remind the resident to ask for assistance as needed Date Initiated: [DATE] CNA Nursing Provide hands on assistance with dressing, grooming, bathing as needed. Date Initiated: [DATE] CNA Provide total staff assistance with dressing, grooming, bathing Date Initiated: [DATE] CNA Encourage resident to take rest breaks during ADL tasks as needed for SOB/ fatigue Date Initiated: [DATE] CNA Nursing Use calm approach. Explain actions during cares. Reapproach prn. Date Initiated: [DATE] CNA Nursing Staff to anticipate resident's needs with ADLs Date Initiated: [DATE] CNA Nursing Therapy to screen as indicated. Date Initiated: [DATE] Therapy Observe for decline in Activities of Daily Living care. FALL CARE PLAN: Ms. [NAME] is at risk for falls r/t impaired mobility and weakness Date Initiated: [DATE] Revision on: [DATE] GOAL The resident will not sustain a fall related injury by utilizing fall precautions through the review date. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] INTERVENTIONS: 1/4 side rails as needed for bed mobility Date Initiated: [DATE] All Anticipate and meet the resident's needs PRN. Date Initiated: [DATE] CNA LPN RN Bed in Lowest position acceptable to resident while resident is in bed Date Initiated: [DATE] CNA LPN RN PT/OT evaluate and treat as ordered or PRN. Date Initiated: [DATE] LPN RN PT Report falls to physician Observations, interviews and record reviews: During observations and record review on [DATE] at 10:10 AM and [DATE] at 11:32 am revealed that Resident 115 that Resident was in a fetal position without a blanket on [DATE] but then up and about in wheelchair on [DATE] providing Physical Therapy for her on [DATE] Dr. vejas. , For the resident using a wheelchair (w/c) or recliner: using wheelchair properly and having staff push her in wheelchair with foot pedals to therapy o The resident is properly positioned in a w/c or recliner to maintain proper body alignment; resident was properly positioned on [DATE] o Seated in a w/c of appropriate size; Resident was seated in an 18 in wheelchair self-propelling to physical therapy on [DATE]o Whether the resident's chair (e.g., w/c or reclining chair) fits under the dining room table so he/she is properly positioned to be able to access the meal; Resident prefers to eat in her room she eats independently. o If the resident self-propels in the wheelchair when able, however, uses foot pedals so her feet do not hang off the wheelchair and the staff assist in wheeling her when needed because she stated that she feels weak with her upper extremities at this time. o Whether the resident is participating and if not, whether staff attempts to engage the resident in the group therapy; Resident is participating in PT OT and SLP as needed since [DATE]. o Whether the resident is positioned ; Resident was positioned appropriately o Whether positioning is provided to prevent complications including during meals;aDuring observation of meal on [DATE] a 12:32 pm, observed Resident in bed eating on side table with water and coffee. Staff set her [NAME]\ql tray up and she used utensils to eat. o The location of all contractures present; no contractures at this time o The condition of the resident's skin: no wound care at this time During observation and interview on [DATE] at 12:32 pm, Resident 115 stated that she ust had a UTI and she feels better now since she had a round of antibiotics. She stated that she is a hoyer lift x2 but now that she has therapy due to weakness from UTI. Do you have any discomfort or pain during treatments, exercise programs, mobility/transfers, application of splints, or positioning? Pain is under control with scheduled pain medication Are you able to actively participate in mobility, positioning, treatments, exercises? Yes I complete PT and OT now Does staff complete the task for you, rather than allowing you to perform it by yourself? Resident 115 stated that staff need to assist her in all activities, she can eat independently and vocalize her needs. [NAME], TORREEN (115) [NAME], [NAME] (51024) - RESIDENT NOTE No Notes

Based on record review and interview the facility failed to ensure a resident who was diagnosed with a serious mental illness received pre-admission screening and resident review (PASARR) program for 1 Resident, Resident #19, of 3 residents reviewed for PASARR. Findings include: Review of Resident #19's admission record documented Resident #19 was admitted on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD) onset date of 10/28/2024, anxiety onset date 8/28/2023 and depressive disorder onset date 8/29/2023 Review of Resident #19's State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 5/4/2024 showed no documentation was entered in Section I: PASRR Screen Decision-Making A. MI [Mental Illness] or suspected MI [Mental Illness] (check all that apply): that recorded Resident #19's diagnosis of post-traumatic stress disorder. Review of Resident #19's State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review (PASRR) read 5. Does the individual have primary diagnosis of : Dementia? No Review of Resident #19's psychiatric progress note dated 12/5/2025 read visit type: Psychiatry: Stable 12-week follow up (on no meds). Documented . past psychiatric history of depression, anxiety, PTSD and insomnia.Diagnostic assessment and plan.post-traumatic stress disorder, unspecified.PTSD (post-traumatic stress disorder): The history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month and have occurred without any substance use or organic brain pathology.Review of Resident #19's care plan, date initiated 9/22/2025, documented Resident #19 had potential for re-traumatization, alteration in thought process related to diagnosis of PTSD. During an interview on 12/17/2025 at 12:22 PM, the Director of Nursing stated the PASSAR does not have diagnosis of PTSD and PTSD should be documented.

Based on observation, interview, and record review the facility failed to ensure resident were provided with wound care as ordered for 1 (Resident#+141) of 3 residents reviewed for skin conditions.Findings include: During an observation on 12/15/2025 at 9:54 AM Resident #141 was lying in bed, Resident #141 eft shoulder wound dressing was dated 12/11. During an observation on 12/16/2025 at 9:12 AM Resident #141 was lying in bed his left shoulder wound dressing was dated 12/11.Review of Resident #141 physician orders dated 12/11/2025 read, Left Upper Arm: Cleanse with NS [normal saline], pat dry, apply calcium alginate to wound bed and cover ABD [abdominal] pad and rolled gauze every evening shift AND as needed.Review of Resident #141 physician order dated 12/11/2025 read, Right Buttock: Cleanse with Dakins 0.125%, allow to air dry, apply medical grade honey, collagen particles and calcium palatinate to wound bed and cover with bordered foam every evening shift AND as needed.Review of Resident #141 physician order dated 12/11/2025 read, LLE [Lower Left Extremity]: Cleanse with NS, Pat dry, calcium alginate to wound bed and cover with ABD pad and kelix every evening shift AND as neededReview of Resident #141 physician order dated 12/11/2025 read, Right Upper Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing every evening shift for wound care AND as neededReview of Resident #141 physician order dated 12/11/2025 read, Right Lower Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing every evening shift AND as needed.During an interview 12/17/2025 at 12:25 PM with the Assistant Director of Nursing #2 (ADON #2) stated, I will round with the wound care provider and then all recommendations I will communicate with the physician, and the physician will have the final say regarding the wound care orders. The wound care orders in the system will supersede any recommendations done by the wound care provider. During an observation on 12/17/2025 at 12:30 with the ADON #2 confirm wound on left should was dated 12/11/2025. During an observation on 12/17/2025 at 1:00 PM with ADON #2 and Staff I Licensed Practical Nurse wound on right lower back, right upper back, left lower extremity and right buttock were dated 12/11/2025 and the right lower buttocks wound was overly saturated.During an interview on 12/17/2025 at 1:15 PM with the ADON #2 stated wounds should be changed daily. During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing (DON) stated, Nurses should check physician orders and provide care based on the orders. Physician orders should be followed. Review of the facility policy and procedure titled Wound Care with the last review date of 6/11/2025 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care procedures and treatments should be performed according to physician orders.

Based on observation, interview, and record review that facility failed to follow infection control standards during wound care for 1 (Resident #141) of 3 residents reviewed for skin conditions and 3 (Resident #6, Resident#75, and Resident #100) of 5 residents reviewed for respiratory services. Findings include: LANE, [NAME] (75) [NAME], [NAME] (45576) - Respiratory Care Oxygen Notes F880 3. Review of Resident #75's clinical record documented admission on [DATE] with diagnosis that included chronic respiratory failure (lungs can't properly exchange oxygen and carbon dioxide), asthma, disorders of the lung, and absence of part of the lung. During an observation on 12/15/2025 at 10:09AM Resident # 75 nebulizer was lying on the ground and open to air. Photograph evidence obtained.During an observation on 12/15/2025 at 3:30 PM Resident # 75 nebulizer was lying on the ground and open to air. Photograph evidence obtained. During an interview on 12/15/2025 at 3:30PM Resident #75 stated I get my breathing treatments every 6 hours if I don't, I can't breathe, yes I received my treatments last night and already twice today, I get them every 6 hours. During an interview on 12/15/2025 at 4:00 PM with Staff D, License Practical Nurse (LPN) stated nebulizer must be placed back in the plastic bags after each use. Review of Resident #75's physician orders dated 11/7/2025 read Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3ML 3 ml inhale orally four times a day for COPD (chronic obstructive pulmonary disease). Review of Resident #75 Medication administration record for December 2025 documented that Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3ML 3 ml inhale orally four times a day for COPD was administered as ordered. 1)During an observation on 12/17/2025 at 12:37 PM Assistant Director of Nursing (ADON #2) asked Staff I Licensed Practical Nurse to perform wound care on Resident #141. Staff I without preforming hand hygiene approached the treatment cart and started to collect items need for wound care. Staff I did not have normal saline in the treatment cart. Staff I returned all the supplies back to the treatment and walked to the central supplies. Staff I return to the treatment cart and without performing hand hygiene retrieved all the wound care supplies. Staff I and ADON walked to Resident #141 room and performed hand hygiene and donned gown and gloves. Staff I did not tie his gown. Staff I gown was loose and portion of torso and shoulders was not cover by the gown. Staff I removed dressing from Resident #141 right buttock. Removed gloves and washed hands. Donned new set of gloves and proceeded to clean wound with a scrubbing motion, going over area that he had cleaned initially. Staff I began to open dressing packet and treatments without preforming hand hygiene. Staff I stopped and went to the bathroom and performed hand hygiene. Staff I applied treatment and dressing. During an interview on 12/18/2025 at 10:10 AM Staff I, LPN, stated, I was nervous but that is no excuse. I should have performed hand hygiene and I should have made sure I had tied my gown properly in the beginning of wound care. I should have clean the wound in a circular motion from inside of wound to the outer portion. Education was provided to me. I was nervous but there is no excuse. During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing stated, Staff should wash their hands before gathering all the supplies. Gown should have been properly donned. Staff should have washed hands before touching the clean supplies. The wound should have been clean in circular motion from inside of wound to the outside so it would not contaminate the clean area. Review of the facility policy and procedure titled Wound Care with a last review date of 6/11/2025 read, Procedure: 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of the facility policy and procedure titled Hand Hygiene with a last review date of 6/11/2025 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 5. Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, ect; l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 6/11/2025 read, Policy: It will be the policy of this facility to implement enhance barrier precautions for preventing transmission of novel or targeted multidrug resistant organisms. Definitions: Enhanced barrier precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Procedure: 4. For residents for whom EBP ae indicated, EBP is employed when performing the following High-Contact resident care activities-h. wound care. 2) During an observation on 12/15/2025 at 9:40AM Resident #6 nebulizer mask was lying on top of a black handbag on top of the recliner not stored in a bag. [photographic evidence obtained] During an observation on 12/15/2025 at 12:40 PM Resident #6 nebulizer mask was lying on top of the black handbag on top of the recliner. Review of Resident #6 physician order dated 12/11/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally four times a day for SOB and wheezing.Review of Resident #6 Care plan intervention dated 6/25/2025 read, store respiratory equipment in infection control bag when not in use.3)During an observation on 12/15/2025 at 12:46 PM Resident #100 nasal cannula was not bagged and hanging on the wheelchair. [photographic evidence obtained]During an observation on 12/16/2025 at 9:08 AM Resident #100 nasal cannula lying on top of the wheelchair not bagged. [photographic evidence obtained]Review of Resident #100 physician orders dated 11/24/2025 read, Oxygen at 2 liters/minute via NC [nasal cannula] with humidification when on concentrator. May be without humidification when on a tank. every shift for hypoxia.Review of Resident #100 Care Plan interventions initiated on 11/26/2025 read, store respiratory equipment in infection control bag when not in use; change q [every] week and prn [as needed]. During an interview on 12/17/2025 at approximately 2:10 PM with the Director of Nursing stated, Every week tubing and mask are changed out and replaced with new ones. The nebulizer mask and nasal cannula should be bagged when not in used. The nurses should verify that it is done.During an interview on 12/18/2025 at 2:43PM with Staff N Licensed Practical Nurse stated, Oxygen nasal cannulas and nebulizer mask should always be bagged when not in use. If resident the resident takes of the nebulizer mask before the treatment is done once the nurses goes back to the room she should verify that the mask is stored in a bag.Review of the facility policy and procedure titled Respiratory Care with a last review date of 6/11/2025 read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedure: 9. After completing the oxygen setup/administration or adjustment, nebulizer treatment, inhaler medication administration or other respiratory treatment, it is appropriate to document in the appropriate locations of the clinical record such as nurses' note, MAR/TAR, ect. When not in use, staff will appropriately store the tubing, mouth devices used for nebulizers or CPAP/BIPAP masks in a manner that promotes infection control practices such as storing in plastic bag when not in use.

Based on observation, interview, record review the facility failed to accurately document wound care treatments for 1 (Resident #141) of 3 residents review for skin conditions and 1 (Resident #99) of 6 residents reviewed for medication management. Findings include:During an observation on 12/15/2025 at 9:54 AM Resident #141 was lying in bed, Resident #141 eft shoulder wound dressing was dated 12/11. During an observation on 12/16/2025 at 9:12 AM Resident #141 was lying in bed his left shoulder wound dressing was dated 12/11.Review of Resident #141 physician orders dated 12/11/2025 read, Left Upper Arm: Cleanse with NS [normal saline], pat dry, apply calcium alginate to wound bed and cover ABD [abdominal] pad and rolled gauze every evening shift AND as needed.Review of Resident #141 physician order dated 12/11/2025 read, Right Buttock: Cleanse with Dakins 0.125%, allow to air dry, apply medical grade honey, collagen particles and calcium palatinate to wound bed and cover with bordered foam every evening shift AND as needed.Review of Resident #141 physician order dated 12/11/2025 read, LLE [Lower Left Extremity]: Cleanse with NS, Pat dry, calcium alginate to wound bed and cover with ABD pad and kelix every evening shift AND as neededReview of Resident #141 physician order dated 12/11/2025 read, Right Upper Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing every evening shift for wound care AND as neededReview of Resident #141 physician order dated 12/11/2025 read, Right Lower Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing every evening shift AND as needed.During an interview 12/17/2025 at 12:25 PM with the Assistant Director of Nursing #2 (ADON #2) stated, I will round with the wound care provider and then all recommendations I will communicate with the physician, and the physician will have the final say regarding the wound care orders. The wound care orders in the system will supersede any recommendations done by the wound care provider. During an observation on 12/17/2025 at 12:30 with the ADON #2 confirm wound on left should was dated 12/11/2025.During an observation on 12/17/2025 at 1:00 PM with ADON #2 and Staff I Licensed Practical Nurse wound on right lower back, right upper back, left lower extremity and right buttock were dated 12/11/2025 and the right lower buttocks wound was overly saturated.During an interview on 12/17/2025 at 1:15 PM with the ADON #2 stated wounds should be changed daily. During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing (DON) stated Nurses should not check off a task as completed until it is fully completed. Documentation should be accurate.During an interview on 12/18/2025 at 12:04 PM with Staff B Registered Nurse (RN) stated, I made a mistake. I was giving report, and I was going to go after to do the dressing change. I had a new admission come in and I was so tired. I forgot to do the dressing changes.Review of the facility policy and procedure titled Wound Care with the last review date of 6/11/2025 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care procedures and treatments should be performed according to physician orders. 10. Document in the clinical record when treatments are performed.2)Review of Resident #99 physician order dated 11/29/2024 read, Metoprolol Tartrate Oral Tablet 25 MG [milligram] (Metoprolol Tartrate) Give 1 tablet by mouth one time a day for HBP [high blood pressure] hold if sbp<110 dbp<60 and or pulse <60 [systolic blood pressure less than 110, diastolic blood pressure less than 60 and or pulse less than 60].Review of Resident #99 Medication Administration Record for the month of December 2025 for Metoprolol Tartrate Oral Tablet 25 mg documented on 12/2/2025 and on 12/9/2025 at 1800 [6:00 PM] blood pressure and pulse documented NA [not applicable].Review of Resident #99 Medication Administration Record for the month of November 2025 for Metoprolol Tartrate Oral Tablet 25 mg documented at 1800 on 11/2/2025 NA documented for pulse, 11/10/2025 NA for blood pressure and pulse, 11/16/2025 NA for blood pressure and pulse, 11/21/2025 NA documented for pulse, and 11/26/2025 NA for blood pressure and pulse.During an interview on 12/18/2025 at approximate 10:10 AM with Staff I Licensed Practical Nurse stated, I don't recall that. Usually, I will take the blood pressure before giving the medication and document it. The facility expects me to document the blood pressure in the medication record. Before I give the medication I always check the blood pressure and make sure it follows physician orders. During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing stated, Vital signs should be recorded in the medication record before the medication is going to be administered. The staff should document blood pressure manually and or in a progress note.Review of the facility policy and procedure titled Charting and Documentation with a last review date of 6/11/2025 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observation, interview and record review, the facility failed to ensure that required food temperature monitoring logs were maintained and complete in 1 of 3 nourishment rooms as evidenced by missing days Based on observation on 12/15/25 at 9:22AM the surveyor observed that the Magnolia Hall nourishment room food temperature log had not been completed for several dates, despite food items requiring temperature monitoring being present.During an interview on 12/15/25 at 9:25AM the Dietary Manager stated that food temperature logs should be documented daily.Review of facility policy titled, Refrigerated Storage review date 10/1/23 showed it reads Foods and Nutrition Services (FNS) should maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled and maintained by dietary staff. Adequate circulation of air around refrigerated products is essential to maintain food temperatures. Procedure: Refrigeration equipment will be monitored by dietary staff daily for adequate temperatures and functionally at routine intervals during hours of operation. Temperatures will be recorded on the appropriate logs to demonstrate monitoring.

Based on record review and interview the facility failed to ensure residents have completed medication orders including dosage for 1 (Resident #25) of 6 residents reviewed for unnecessary medications.Findings include:Review of Resident #25 physician orders dated 10/9/2025 read, Lidocaine Pain Relief 4% Patch. Apply to per additional directions topically one time a day for pain at night.Review of Resident #25 physician orders did not have an order for removal of Lidocaine Pain Relief Patch. Review of Resident #25 physician orders dated 9/9/2025 read, Diclofenac Sodium External Gel 3 % (Diclofenac Sodium (Actinic Keratoses) apply to bilateral knee topically two times a day for knee pain. Review of Resident #25 physician orders dated 11/12/2025 read, Diclofenac Sodium External Gel 1% (Diclofenac Sodium Topical) apply to right knee topically three times a day for right knee pain.During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing stated, [Resident #25 name] has no removal orders for lidocaine patch. There should be an additional order for the removal. Diclofenac does not have a dose amount included and it should. It was part of an old batch orders and needs to be updated. Review of the facility policy and procedure titled Pharmacy Services with a last review date of 6/11/2025 read, Policy: It will be the policy of this facility to provide pharmacy and pharmacist services to meet the needs of the resident. 2Procedrue: 1. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. 2. Pharamcist must report any irregulates to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection by not completing sanitization of blood pressure cuffs, hand hygiene during medication administration, and hand hygiene after the delivery of personal care. Findings include: 1. During an observation on 7/16/2024 at 09:00 AM Staff B, License Practical Nurse (LPN) retrieved the blood pressure cuff from the top of the medication cart and obtained a blood pressure reading for Residents #55. Staff B, LPN returned to the medication cart and placed the blood pressure cuff inside the cart without cleaning/sanitizing the cuff. During an interview on 7/16/2024 at 09:17 AM Staff B, LPN stated, Blood pressure cuffs are to be wiped after each use with Clorox wipes. I should have cleaned the blood pressure cuff after using it. 2. During an observation on 7/16/2024 at 09:25 AM Staff D, Registered Nurse (RN) exited the nutrition room and initiated medication administration for Resident #103. Staff D pulled the wrong medication, then destroyed the wrong medication in a drug buster, opened the bottom drawer of the medication cart, and secured the drug buster. Staff D, RN did not perform hand hygiene and proceeded with preparing the correct medications for Resident #103. Staff D went to administer the medications to Resident #103, Staff D did not perform hand hygiene and attempted to administer the medications. Resident #103 refused to take the medications. Staff D did not perform hand hygiene, exited Resident #103's room, returned to the medication cart and destroyed the medications, did not perform hand hygiene, and proceeded to prepare medications for Resident #122. Staff D did not perform hand hygiene and administered the medications to Resident #122. Staff D did not perform hand hygiene, exited the resident's room, returned to the medication cart, did not perform hand hygiene, and proceeded to prepare medications for Resident #62. Staff D removed the medications from their containers, put them in a bag and crushed the medications for Resident #62. Staff D did not perform hand hygiene and administered the medications to Resident #62. Staff D did not perform hand hygiene, exited Resident #62's room and returned to the medication cart. During an interview on 7/16/2024 at 10:20 AM Staff D, RN stated I did not do hand hygiene and I should before and after medication preparation and administration. During an interview on 7/16/2024 at 12:50 PM the Director of Nursing (DON) stated, The expectation is for hand hygiene to be completed before and after contact with each patient and before and after medication preparation and administration for each resident. The blood pressure cuffs are to be cleaned before and after each resident use. 50695 3. During an observation on 07/15/24 at 01:50 PM, Staff G, CNA (Certified Nursing Assistant) was observed coming into the doorway of a resident's room holding a soiled brief, with gloves on. She stood in the doorway and spoke with a visitor from another room, and then placed the brief in a trash bag. While wearing the same gloves, Staff G assisted Resident #48 into a wheelchair, she then picked up the resident's hairbrush, brushed the resident's hair and wheeled him out of the room. During an interview on 07/15/24 at 2:10 PM, Staff G, CNA stated, I didn't wash my hands after peri-care. I usually do, if I have time. During an interview on 07/15/24 at 02:55 PM, the Director of Nursing stated, I expect my staff to remove their gloves and wash their hands after providing patient care. Review of the policy and procedure titled Hand Hygiene dated 1/25/2024 read, This facility considers hand hygiene the primary means to prevent the spread of infections. 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with resident's intact skin.

Based on observation, interview, and record review the facility failed to ensure foods were prepared under sanitary conditions and failed to ensure food temperatures were documented to be at safe levels prior to meal service to residents. Findings include: An initial tour of the facility kitchen was completed on 7/14/2024 beginning at 9:16 AM. There was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was a black discoloration on the large ceiling vent above the same food preparation area. There were uncovered peeled bananas on the counter underneath the discolored ceiling and ceiling vent. During a follow-up tour of the kitchen on 7/17/2024 beginning at 8:36 AM, there was a black discoloration on the ceiling surrounding the large air conditioning vent above a food preparation area. There was black discoloration on the large ceiling vent above the same food preparation area. There were two large baking sheets of uncovered raw chicken pieces on the counter underneath the discolored ceiling and ceiling vent. During an interview on 7/17/2024 beginning at 8:29 AM, the Dietary Manager acknowledged the ceiling area surrounding the ceiling and the ceiling vent above the food preparation area was dirty and needed to be cleaned. Review of the facility policy and procedure titled Kitchen Sanitation, last reviewed 1/25/2024, read, It is the policy of the facility that the food service area and equipment shall be maintained in a clean and sanitary manner. During a follow-up tour of the kitchen on 7/17/2024 beginning at 8:36 AM, kitchen staff were observed placing breakfast foods on plates for service to residents. Review of the food temperature log dated 7/17/2024 for the morning meal on 7/17/2024 at 8:36 AM, failed to reveal documentation food temperatures had been taken of the morning meal menu items before the meal was served to residents. During an interview on 7/17/2024 beginning at 8:29 AM, the Dietary Manager acknowledged there was no documentation that temperatures of the morning meal menu items had been taken before serving the meal to residents. She stated morning meal service had started at 7:30 AM. Review of the policy and procedure titled Final Cooking Temperatures, last reviewed 1/25/2024, read, Food is to be cooked to specified temperatures and times to mitigate the presence of dangerous microorganisms. Review of the policy and procedures titled Food Temperatures, last reviewed 1/25/2024, read, Foods will be maintained at proper temperature to insure food safety. 3. The cook is responsible to see that all food is at the proper temperature. 4. The temperature will be taken and recorded for all items at all meals. Record temperatures on extended menus.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care services, Residents #591 and #80. (Photographic evidence obtained) Findings include: 1. During an observation on 7/14/24 at 10:00 AM Resident #591 was observed resting in bed wearing a nasal cannula and the oxygen (O2) concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an observation on 7/14/24 at 1:04 PM Resident #591 was observed sitting at the edge of the bed wearing a nasal cannula and the O2 concentrator was administering oxygen at 5 liters with a humidifier bottle attached. During an interview on 7/14/24 at 1:04 PM Resident #591stated, I don't touch or adjust the settings on the oxygen concentrator. The staff is the one who touches the settings. During an observation on 7/15/24 at 8:09 AM Resident #591 was observed resting in bed eyes closed wearing a nasal cannula and the oxygen concentrator was observed administering oxygen at 3 liters. During an observation on 7/16/24 at 7:45 AM Resident #591 was observed resting in bed eyes closed wearing a nasal cannula and the oxygen concentrator was observed administering oxygen at 3.5 liters. During an interview on 7/16/24 at 7:51 AM Staff F, Licensed Practical Nurse (LPN) stated, I check the O2 setting every day. I know the O2 is supposed to be on 2 liters, I think he changes the setting himself. Review of the physician order dated 6/30/24 at 12:48 PM read, 02 2 L NC [oxygen at 2 liters via nasal canula]. 45576 2. During an observation on 7/14/2024 at 09:40 AM of Resident #80 it showed oxygen was being administered at 2.5 liters via nasal cannula. The humidified water bottle was empty. During an observation on 7/15/2024 at 2:45 PM of Resident #80 it showed oxygen was being administered at 2.5 liter via nasal cannula. The humidified water bottle was empty, and the humidified water bottle and tubing were dated 7/7/2024. Record review of Resident #80's physician order dated 6/14/2024 read, Change oxygen tubing and humidified H2O [water] weekly and PRN [as needed]. During an interview on 7/15/2024 at 2:55 PM Staff A, License Practical Nurse (LPN) stated, That oxygen tubing and humidification tubing is changed weekly, normally on night shift. The humidification bottle is empty, and the humidification bottle and tubing are dated 7/7/2024. This tubing should have been changed when there was no more water or weekly. During an interview on 7/15/2024 at 3:10 PM Staff C, LPN stated, I am assigned to the resident today and did not assess the oxygen delivery system for the oxygen delivery rate, the humidification bottle or the tubing and the dates on the humidification bottle and tubing. During an observation on 7/15/2024 at 3:11 PM with the Director of Nursing (DON) the DON confirmed the humidified water container was empty and the humidification bottle and tubing was dated 7/7/2024. During an interview on 7/15/2024 at 3:11 PM the DON stated, Humidified water is to be changed when it is empty, and tubing is to be changed weekly. Review of the policy and procedure titled Oxygen Administration Issued 4/1/2022, last reviewed 1/25/24 read, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: .4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed to maintain infection control standards.

Based on observation and interview the facility failed to ensure maintenance and housekeeping provided the services necessary to maintain a sanitary and orderly environment for the 200-hall shower room. Findings include: During an observation on 7/14/24 at 10:00 AM during the initial tour of the 200-hall shower room it was observed that the ceiling, walls, and tiles surrounding the shower area were cracked and/or have holes. The walls of the shower room have streaks of a darkened green and brown substance running down the walls. It was also observed to have dirty linen and personal items that were left in the shower room. During this observation the shower floor was dry as were the walls. (Photographic evidence obtained) During observations on 7/15/24 staff were observed wheeling residents into the shower room on the 200-hall for showers. During an observation on 7/15/24 at approximately 10:00 AM the shower room walls in the shower room on the 200-hall were observed to have streaks of a darkened green and brown substance running down the wall. During observations on 7/16/24 staff were observed wheeling residents into the shower room on the 200-hall for showers. During an observation on 7/17/24 at approximately 9:45 AM the shower room walls in the shower room of the 200-hall were observed to have streaks of a darkened green and brown substance running down the wall. During an interview on 7/17/24 at 10:00 AM, while in the 200-hall shower room, the Maintenance Director stated, This is an area that is a concern. I am aware that it needs to be fixed, it is on my list. The housekeeping lead tells me that they clean the shower room daily. During an interview on 7/17/24 at 10:10 AM the Housekeeping Lead stated, I get a ticket that shows me that the cleaning is completed daily. I do not make a habit of checking after the staff. I can say they [the shower room walls] need to be cleaned. During an interview on 7/17/24 at 10:30 AM the Director of Nursing stated, Staff should not leave personal items, or linens in the shower room. My expectation is that staff are supposed to leave the shower room ready for the next person to use. Review of policy and procedure titled P&P Environmental Services Cleaning Guidelines Issued 4/1/2022, last reviewed 1/25/24 read, Policy: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule and documentation based on the area of the facility, type of surface to be cleaned, type of soil present and task being performed in the area. Purpose: It is important that a clean, safe and sanitary environment is maintained for our residents.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and two medication errors were identified for 1 of 6 residents. The medication errors resulted in a medication error rate of 7.14%. Findings include: During an observation on 7/16/2024 at 9:50 AM of Staff C, Registered Nurse (RN) during the medication pass for Resident #62 it showed Staff C administered one Midodrine HCL (hydrochloride) oral tablet 5 mg (milligrams), and one Vitamin D3 tablet 215 mg/equivalent to 5000 IU (international units). Resident #62's blood pressure results were documented as 140/88. Review of Resident #62's physician orders dated 5/6/2024 read, Vitamin D3 oral tablet give 3000 units by mouth in the morning for supplement. Midodrine HCL oral tablet 5 mg give 1 tablet by mouth three times a day for hypotension [low blood pressure] hold if systolic is greater than 110. During an interview on 7/16/2024 at 11:50 AM Staff D, RN stated, Midodrine should not have been given because his [Resident #62] blood pressure was not within the parameters as written, a systolic blood pressure less than110, and the Vitamin D should have been 3000 units not 5000 units. During an interview on 7/16/2024 at 4:15 PM the Director of Nursing stated, Midodrine is to be administered as ordered when the blood pressure falls within the parameters written and all medications are to be given as ordered. Review of the policy and procedure titled Medication Administration revised on 01/25/2024, read, It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by the resident. 3.Medication should be administered in a timely manner and in accordance with the physician's orders. 5. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director for further instructions. 8. After successfully identifying the resident to receive medication administration, the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified.

Based on observation, interview, and policy and procedure review the facility failed to ensure medications were secure allowing access by unauthorized personnel, residents, and visitors when medications were left unattended on a resident's bed. Findings include: During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room with Staff E, LPN, she confirmed the medications in the medication cup were on Resident #491's bed and were unattended. During an interview on 7/14/24 at 1:45 PM Staff E, LPN stated, These were from 10:30 AM this morning. I brought them into [Resident 491's room] and she [Resident #491] wasn't here, but then I got distracted by the roommate and the roommate's family, and then I forgot the medications in the room. Staff E identified the medications as lisinopril [for elevated blood pressure], diltiazem [for elevated blood pressure], apixaban [a blood thinner], fluoxetine [for depression], memantine [for dementia], pantoprazole [for gastroesophageal reflux disease], and nitrofurantoin [an antibiotic to treat infection]. During an interview on 07/16/24 at 11:44 AM, the Director of Nursing stated, My expectation is that the nurse must find that resident and give those medications to the resident, stay and watch the resident take those medications. Staff should never have left those medications behind in the room unsecured and unattended. Review of the policy and procedure titled Medication/Biological Storage issued 4/1/2022, last reviewed 1/25/2024 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems.

Based on observation, interview, and record review the facility failed to ensure the accuracy of medical records when errors were identified by licensed nursing staff for medication administration for 1 of 5 residents, Resident #491 and failed to ensure accurate and complete records for 1 of 2 residents, Resident #49, reviewed for hospitalization s. Findings include: 1. During an observation on 07/14/24 at 1:00 PM, there was a medication cup on Resident #491's bed containing seven pills, one green/white capsule, two white tablets, two pink tablets and two yellow tablets. The resident's bed was made, and the resident was not in the room. The resident's roommate was in the room in bed, with two family members visiting. The unsecured medication was in plain sight of the open doorway, where staff, residents and visitors were observed in the hallway. During an observation on 7/14/24 at 1:19 PM, the unsecured medications continued to be observed on Residents #491's bed. Resident #491 was not in the room. During an observation on 7/14/24 at approximately 1:45 PM of Resident 491's room with Staff E, LPN, she confirmed the medications in the medication cup were on Resident #491's bed and were unattended. During an interview on 7/14/24 at approximately 1:45 PM Staff E, LPN stated, These were from 10:30 AM this morning. I brought them into [Resident 491's room] and she [Resident #491] wasn't here, but then I got distracted by the roommate and the roommate's family, and then I forgot the medications in the room. Staff E identified the medications as lisinopril [for elevated blood pressure], diltiazem [for elevated blood pressure], apixaban [a blood thinner], fluoxetine [for depression], memantine [for dementia], pantoprazole [for gastroesophageal reflux disease], and nitrofurantoin [an antibiotic to treat infection]. Review of the Medication Administration Record (MAR) on 7/16/24 documented dated 7/14/24 at 9:00 AM lisinopril, diltiazem, apixaban, fluoxetine, memantine, pantoprazole, and nitrofuratoin were administered to Resident #491. Review of the nursing progress notes for 7/14/24 through 7/16/24 at 9:00 AM provided no documentation the medications for Resident #491 were destroyed, were administered late, were not administered, of notification to the physician that medications were not administered as ordered, and/or for orders to administer the medications or to hold the medications. During an interview on 07/16/24 at 03:14 PM, the Director of Nursing stated The nurse did not give the medications to the resident and did not call the doctor. During an interview on 07/17/24 at 09:41 AM the Director of Nursing stated, It is my expectation that the nurse should have called the doctor and family when the medications were not given. The nurses must follow physicians' orders. The nurse should have told the physician the names of the medications, how late it was, and if it can be given now. She then should have charted everything that she did and put in a nurse's note because you cannot reverse what was put on the MAR. This was not done. Review of the policy and procedure titled Medication Administration, last reviewed on 1/25/24, read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medications or refusals of medication by the resident. Procedure: 7. Medications should be administered within one (1) hour before or after their prescribed time. 12. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication will document this in the clinical record. 16. Should a resident be away from his/her room or unavailable during the medication pass, it is permissible to return during the appropriate time frame to that resident at a later time to complete the administration. 50695 2. Review of Resident #49's progress note dated 5/8/24 read, Type: Event Note. Effective Date: 5/8/2024 15:43 [3:43 PM]. Note Text: Resident was driving her motorized chair to her room when she lost control of her chair and drove it into her bedframe causing a large laceration to her left lower extremity. Bleeding was controlled and 911 called. EMS [emergency medical services] transported Resident to [name of hospital] at 1530 [3:30 PM]. Review of the medical record for Resident #49 did not provide documentation of the transfer form to a higher level of care or for the change in condition for the event dated 5/8/2024. Review of Resident #49's progress note dated 6/5/24 read, Type: Event Note. Effective Date: 6/5/2024 18:06 [6:06 PM]. Note Text: Resident presented with a change of condition by not responding as her usual. Vitals within normal limits. O2 sat [oxygen saturation level] is 97%. Scant twitching noted systemically. Order obtained to send resident to E.R. [emergency room ] for further evaluation. Called son to notify. Review of the medical record for Resident #49 did not provide documentation of the transfer form to a higher level of care or for the change in condition for the event dated 6/5/2024. During an interview on 7/16/24 at 2:50 PM the Director of Nursing stated, [Resident #49's name] went out to the hospital on 5/8/24 due to an accident in her wheelchair and came back that night, on 6/5/24 because she was septic. They have their notes [progress notes] in the chart, but there aren't any transfers or change in condition forms. The expectation is that they complete transfer and change in condition forms when they send patients out [to the hospital].

Based on observation, interview and record review the facility failed to ensure accurate nurse staffing information was posted on a daily basis for 3 of 6 days. Findings include: Observation of the displayed nurse staffing information on Sunday, July 14, 2024 at 9:05 AM showed nurse staffing information for Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024 was posted in the front lobby area of the facility. A comparison review of the actual staff working hours on Friday, July 12, 2024, Saturday, July 13, 2024, and Sunday, July 14, 2024 with the Staffing Coordinator revealed the posted nurse staffing information did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses and certified nurses aides on Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024. During an interview on 7/16/2024 at 10:49 AM, the Staffing Coordinator stated the displayed nurse staffing information were projections and did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses and certified nurses aides on Friday, July 12, 2024, Saturday, July 13, 2024 and Sunday, July 14, 2024. She stated she posted the projected nurse staffing sheets on Thursday evenings for Fridays, Saturdays, Sundays and Monday. Review of the facility policy titled Staff Postings, last reviewed 1/25/2024, read, Policy: It will be the policy of this facility to display staff posting information for visitors, families, residents and staff to be able to see. (1) Data requirements. The facility will post the following information on a daily basis: .(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. 2. Posting requirements. (i) The facility will post the nurse staffing data specified data on a daily basis at the beginning of each shift.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with professional standards of practice in 6 of 6 medication carts reviewed for medication storage. Findings include: During an observation of Medication Cart #1 on [DATE] at 8:40 AM with Staff A, Licensed Practical Nurse (LPN), there were one opened Humalog insulin with no date opened or expiration date, one opened Lispro insulin with no date opened or expiration date, two unopened Aspart insulin with pharmacy instructions to refrigerate until opened, one opened bottle of olopatadine eye drops with no date opened or expiration date, one opened bottle of Prednisolone eye drops without the original pharmacy packaging and no date opened or expiration date, and two opened bottles of artificial tears with no dates opened or expiration dates. During an observation of Medication Cart #2 on [DATE] at 8:51 AM with Staff A, LPN, there were one opened Humalog insulin with no date opened or expiration date, one opened Lantus insulin with no date opened or expiration date, and one opened Humulin N insulin with date opened of [DATE] with pharmacy instructions to discard after 42 days. During an interview on [DATE] at 8:52 AM, Staff A, LPN, stated, Eye drops and insulin should have labels and dates when opened or when they should expire. Expired insulin should not be on the cart. During an observation of Medication Cart #3 on [DATE] at 8:58 AM with Staff B, LPN, there were one opened Latanoprost eye drops with no date opened or expiration date, one unopened latanoprost eye drops with pharmacy instructions to refrigerate until opened, and one opened Lispro insulin with no date opened or expiration date. During an observation of Medication Cart #4 on [DATE] at 9:05 AM with Staff B, LPN, there were two unopened Humalog insulin with pharmacy instructions to refrigerate, two opened Latanoprost eye drops with no dates opened or expiration dates, one opened Timolol eye drops with no date opened or expiration date, and one opened Brimonidine eye drops with no date opened or expiration date. During an interview on [DATE] at 9:07 AM, Staff B, LPN, stated, We do label all insulin and eye drops with the date we open them, and any medications should be thrown out if they are expired. Insulin should stay in the refrigerator until it is opened. During an observation on [DATE] from 9:12 AM through 9:18 AM, Medication Cart #5 was unlocked and unattended. At 9:18 AM, Staff C, LPN, returned to the medication cart. During the period the medication cart was unattended, there were three staff members and two residents passing by the medication cart. During an interview on [DATE] at 9:18 AM, Staff C, LPN, stated, I shouldn't have left the cart unlocked. During an observation on [DATE] from 9:21 AM through 9:26 AM, Medication Cart #6 was unlocked and unattended. At 9:26 AM, Staff D, Registered Nurse (RN), returned to the medication cart. There were one opened Ofloxacin 0.3% eye drops with no date opened or expiration date, seven bottles of artificial tears with no dates opened or expiration dates, and one unopened Lantus insulin with pharmacy instructions to refrigerate until opened. During an interview on [DATE] at 9:28 AM, Staff D, RN, stated, I should not have left the cart unlocked. We should not have any meds unlabeled. It [insulin] should be in the refrigerator. During an interview on [DATE] at 10:02 AM, the Director of Nursing stated, I expect that all staff will have the medication carts locked at all times when they are away from the carts. All medications should be labeled when they are opened and discarded if they have expired. I expect them to follow our policies. Review of the facility policy and procedure titled Medication/Biological Storage issued on [DATE] read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure . 4. The facility should not use discontinued, outdated or deteriorated medications, drugs or biologicals . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view . 10. Medications requiring refrigeration must be stored in a refrigerator located in a drug room at the nurses station or other secured location. Medications must be stored separately from food and must be labeled accordingly.

Based on record review and interview, the facility failed to ensure a written bed-hold notice that included all required information was provided to the residents and/or their representatives for 3 of 3 residents reviewed for hospitalization , Residents #47, #191, and #54. Findings include: 1. Review of the admission record for Residents #47 revealed the resident was admitted to the facility on [DATE]. During an interview on 3/6/2023 at 12:36 PM, Resident #47 stated, I went to the hospital in the beginning of January and the end of December most recently. They did not give me any bed hold notices when I left. What are those anyway? Review of the nursing progress note for Resident #47 dated 1/4/2023 at 4:01 AM reads, On 1/4/23 around 0020 [12:20 AM] the resident put on his room call light to notify nursing staff he was having SOB [Shortness of Breath] and asked if he could now go to hospital to be seen, upon entering the room the resident displayed signs and symptoms of shortness of breath and labored breathing, head of bed was elevated and O2 [oxygen] at three liter nasal cannula was on the resident, vital signs taken, resident O2 saturation noted in the high 70s low 80s, non rebreather was placed on resident, MD [Medical Doctor] contacted new order obtained to send to ER [emergency room ] for further evaluation. Resident brother [Resident #47's Brother's name] notified of resident condition and transferred to hospital. Review of Resident #47's medical records revealed no evidence the facility provided the resident or resident representative with written information that specified the duration of the bed-hold policy upon transfer to the hospital. During an interview on 3/8/2023 at 3:00 PM, the Director of Nursing (DON) stated, I can't find evidence that there is a bed hold that was provided to the resident or their representatives. I didn't know they weren't being done. I think the nurses or social service should do that when the resident leaves. 2. Review of the admission record for Resident #191 revealed the resident was admitted to the facility on [DATE]. Review of Resident #191's SBAR (Situation, Background, Assessment, Recommendation) interact change of condition dated 6/19/2022 at 9:47 PM documented the resident was unresponsive with low bp (blood pressure), low O2 sat (oxygen saturation) with a recommendation from doctor to send to ER for evaluation. Review of Resident #191's medical records revealed no evidence the facility provided the resident or resident representative with written information that specified the duration of the bed hold policy upon transfer to the hospital. During a telephone interview on 3/8/2023 at 8:35 AM, Resident #191's representative stated, I was not provided any bed hold policy or paperwork from the nursing home. I don't even know what that is. During an interview on 3/8/2023 at 11:30 AM, the DON stated, I don't see any evidence or documentation that we provided the resident or his wife the bed hold policy. 3. Review of the admission record for Resident #54 revealed the resident was admitted to the facility on [DATE]. Review of the nursing progress note for Resident #54 dated 1/14/2023 at 5:39 PM reads, Resident sent out to ER for abnormal labs hemoglobin 6.1. Review of Resident #54's medical record revealed no evidence the facility provided the resident or resident representative with written information that specified the duration of the bed hold policy upon transfer to the hospital. During an interview on 3/7/2023 at 10:22 AM, Resident #54 stated, I went to the hospital in January. I wasn't given any kind of notice about my bed hold. I'm not sure what you are talking about. During an interview on 3/8/2023 at 11:35 AM, the DON stated, There is no bed hold in his chart. It appears we did not give him one. It is the responsibility of the nurses to do this. On 3/8/2023 at 11:35 AM, the DON was requested the facility bed hold policy. No documentation was received.