Every finding on record at Lake City Healthcare and Rehabilitation Center

Based on observation, interview, and record review the dietary department failed to store, prepare, and serve food in a sanitary manner for the resident for 1 of 2 observations of the kitchen. Findings include:During an initial tour of the kitchen on 8/9/2026 at 9:10AM with Staff S [NAME] there was a pitcher of lemonade that was placed on top of the ice machine and a bowl of oatmeal placed on top of the serving area for plates. A clear bag of sausage links was placed on to of a plastic cart. The package was not dated or labeled.During an interview on 8/9/2026 at 9:13 AM with Staff S [NAME] stated, Sausage package was opened yesterday it should have been dated and stored in the refrigerator when not in use.During an observation on 8/9/2026 at 9:16 AM with Staff S [NAME] the walk in refrigeratior had a plastic container with aluminum foiled covering the container which was inside another pan with ice. The aluminum foiled had labeled chicken but no date. The chicken was stored in the second shelve on top of the potatoes.During an interview on 8/9/2026 at 9:17 AM with Staff S [NAME] stated, This chicken will be used tomorrow. It should have been stored in the bottom shelf and it should have been dated before being stored in the refrigerator.During an observation on 8/9/2026 at 9:35 AM with Staff T Lead [NAME] of [NAME] Hall refrigerator did not have a thermometer.During an interview on 8/9/2026 at 9:35 am with Staff T Lead [NAME] confirm no thermometer could be located inside of the refrigerator and would need to get one to place inside the refrigerator.During an observation on 8/11/2026 at 11:30 AM Staff T Lead [NAME] was observed grabbing small bowls touching the inside of the bowl were food would be store. Staff T was observed multiple times during meal serving grabbing at times five bowls at a time and placing her hand inside the last bowl on the bottom row. Then serving carrots in the bowls. Staff U [NAME] was observed preparing grill cheese sandwiches she was observed using the spatula and touching the grilled cheese sandwich with her gloved hand to flip the bread over. Staff T Lead [NAME] asked Staff U [NAME] to hand her a bowl. Staff U [NAME] without changing her gloves or performing hand hygiene return to flipping the grill cheese using her hands and the spatula. Staff U [NAME] was observed putting away cheese in a cooler across where she was preparing the grill cheese and without hand hygiene or changing her gloves return to the station and using her gloved hands grabbed the grill cheese sandwich and put them into a container. During an interview on 8/11/2026 at 1:20 PM with the Assistant Dietary Manager stated, The lemonade should have been stored in the cooler and not left on top of the ice maker, sausages should be put back in the freezers when the staff were done with them inside a ziplock bag and it should have been labeled and dated. The chicken should be dated and stored in the bottom rack. The potatoes should have been store in the second shelve and the chicken on the bottom shelve. Refrigerator should have a thermometer inside. I checked Friday and it was one upfront not sure what happened over the weekend. Staff should have grab the bowl by the outside never touching the inside of the blow. Staff should have washed hands and change gloves when handling food.Review of the facility policy and procedure titled Dating and Labeling Policy with a last review date 1/20/2026 read, Policy: Kitchen will assure food safety by maintaining proper dates and labels to all goods and ready to eat food products. Procedure: 2. Label products in storage with date the package was opened.

Based on observation, interview, record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #6) of 2 residents reviewed for dialysis and 1 (Resident #18) of 3 residents reviewed for urinary catheter devices. Findings include: 1)Review of Resident #6 's care plan initiated on 5/21/2026 interventions read, provide, serve diet as ordered. Monitor intake and record q [every] meal. Review of Resident #6's Task ADL [activities of daily living] Eating and Meal Percentage did not document meal intake percentage for 7/16/2026, 7/17/2026, 7/18/2026, 7/23/2026, 7/25/2026, 7/30/2026, 8/1/2026, 8/3/2026, 8/4/2026, 8/6/2026. Review of Resident #6's physician order dated 5/20/2026 read, Renal diet Regular texture, Regular/Thin Liquids consistency, 1000ml [milliliters] fluid restriction. During an interview on 8/12/2026 at 12:22 PM, Staff H, Certified Nursing Assistant, stated, When [Resident #6's Name] comes back from dialysis we will get him something to eat for lunch. We are to record the meal intake after every meal in point click care. During an interview on 8/12/2026 at 12:30 PM with the Director of Nursing stated, [Resident #6's Name] will come back from dialysis and will have lunch in the facility. Normally we will get him a new tray or a chef salad. He normally gets a chef salad. The staff should record the intake of whatever it is given to him and what is eaten. 2.) Review of Resident #18 Care Plan initiated 06/07/2026 did not include Resident provides self-care of suprapubic catheter. During observation on 08/09/2026 at 9:55AM Resident #18's Foley bag was hanging from the bedside frame, and attachment nozzle was exposed/uncapped and lying on bed. During an interview on 08/09/2026 at 10:00AM, Staff P, LPN, stated [Resident #18's Name] switches to the leg bag himself. He is very independent. The tip should be covered. During an interview with Resident #18 on 08/10/2026 at 9:01AM reported he wears the bigger bag at night and puts the leg bag on in the morning himself. He stated, I am [Age of Resident #18] years old I have been taking care of myself all my life. During an interview with the ADON (Assistant Director of Nursing) Infection Control Nurse on 08/11/2026 at 12:35PM, she stated each time a new leg bag is opened it comes with a blue cap. It does need to be covered when he switches it and leaves it on the bed. During interview with Staff Q, LPN (licensed practical nurse) MDS (Minimum Data Set) on 08/12/2026 at 2:21 PM, she stated a Resident should be Care Planned for self-management of foley after nursing has evaluated and educated the Resident. Review of Resident #18's MDS (Minimum Data Set) 06/07/2026 Annual Section H documented Indwelling catheter Foley. Review of Resident #18's physician orders read, Suprapubic (flexible tube placed directly into your bladder through a small cut in your lower abdomen to drain urine) catheter care every shift every shift 12/12/2025. Review of the facility policy and procedure titled Clinical-Care Plan with a last review date of 1/20/2026 read, Purpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and interventions to meet the resident's physical, psychosocial and functional needs.

Based on observation, interview, and record review, the facility failed to notify residents' physicians and/or Resident Representatives for three (Resident #2, Resident #37 and Resident #28) of ten residents reviewed for skin issues, one (Resident #11) of three reviewed for ADL (Activities of Daily Living) care, and one (Resident #30) of three reviewed for accidents. Findings include: During an observation on 8/09/2026 at 10:26 AM Resident #37 was lying in bed on her left side. There was a bandage on her lower right forearm dated 8/7. During an interview on 8/09/2026 at 1:22 PM Resident #37's daughter/Responsible Party stated that she had noticed the bandage on her mother's arm. She presumed it was a skin tear. The facility had not notified her of the injury. During an interview on 8/10/2026 at 1:55 PM Staff B, LPN stated that if a resident had a new skin issue, such as a skin tear, she would assess the resident and try to determine what had happened. If there had been a witness to an event, she would obtain a witness statement. She would notify the family and notify the physician and get wound care orders. If the Wound Care provider needed to see the resident, she would notify them. Review of Resident #37's face sheet revealed she was admitted on [DATE] with medical diagnoses that included metabolic encephalopathy (primary); dysphagia, oropharyngeal phase; weakness; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; aphasia; extended spectrum beta lactamase (ESBL) resistance; cognitive communication deficit; hypoglycemia, unspecified Review of Resident #37's Physicians' Orders revealed an order dated 8/04/2026 read, Skin tear: Cleanse area to bilateral arms with wound cleanser, apply TAO (triple-antibiotic ointment) to site and cover bordered gauze QOD (every other day) until healed. every day shift every other day for skin tear Review of Resident #37's Physicians' Orders revealed an order dated 6/21/2026 that read, Wound care: Right Wrist- cleanse with wound cleanser. Apply TAO to wound bed. Place non-adherent dressing to wound bed and wrap with rolled gauze. Daily and as needed every day shift for Skin Tear Review of Resident #37's Progress Notes from 6/1/2026 through 8/10/2026 revealed no documentation regarding notification to a provider or the Resident Representative regarding Resident #37's wounds/dressings. Review of Resident #37's most recent MDS Assessment, a quarterly assessment dated [DATE] documented no BIMS (Brief Inventory of Mental Status) Score. She required substantial/maximal assistance or was dependent on staff for all self-care activities. Review of Resident #37's Care Plan revealed the following: Focus - The resident has potential impairment to skin integrity r/t (related to) fragile skin, incontinence, limited mobility / LLE (left lower extremity) Interventions included - Follow facility protocols for treatment of injury. Focus - The resident has a Skin Tear of bilateral arms. Interventions included - If skin tear occurs, treat per facility protocol and notify MD (medical doctor), family. During an interview on 8/11/2026 at 11:26 AM Physician #1 stated that he could not recall receiving a call regarding Resident #37 having a wound. Education may be needed for the nurses regarding wound care and provider notification. If the Wound Care Nurse or a Staff Nurse had received an order for wound care, they should have documented the assessment and the conversation. During an interview on 8/11/2026 at approximately 12:00 PM Staff R, RN stated that if a resident had a skin tear or wound with any bleeding, she would treat it right away to stop the bleeding and document her assessment and the care provided. She would inform the doctor, the Unit Manager and the DON. The family would be notified as well. During an interview on 8/11/2026 at 2:24 PM Physician #1 stated that Best Practice for new or worsening wounds would be for the nurse to assess the issue, contact the provider and discuss and confirm an order. As the Medical Director, he was available if other providers could not be reached. During an interview on 8/11/2026 at 1:05 PM Staff A, RN - Wound Care Nurse stated that she had assessed Resident #37 on 8/04/2026 and discovered that she had wounds on her bilateral forearms with dressings already in place. She had removed the dressings, cleaned the wounds, and applied new dressings. She had entered the wound care orders in the computer. She did not write a progress note or contact a provider to report her findings or confirm the wound care order. She did not contact Resident #37's family regarding the wounds. During an interview on 8/11/2026 at 1:23 PM the DON (Director of Nursing) stated that the Wound Care Nurse was expected to notify family and a provider if she identified a new or worsening wound. The Wound Care Nurse or Staff Nurse was expected to contact a provider for any wound care orders. 2) Review of Resident #2's Physicians' Orders from 8/01/2026 through 8/11/2026 revealed an order dated 8/04/2026 that read, Skin Tear: Cleanse skin with wound cleanser of choice. Apply TAO to open area to left lateral ankle and apply non adherent or silicone dressing until healed every day shift for wound care The order was entered by Staff A, RN as a verbal order from Physician #2 on 8/04/2026 at 9:55 AM. Review of Resident #2's Progress Notes from 8/01/2026 through 8/11/2026 revealed there was no documentation regarding a skin tear, notification to family or provider, or treatment orders for wound care. Review of Resident #2's Care Plan revealed the following: Focus - The resident has potential for impairment to skin integrity. Interventions included - Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (medical doctor). Focus -The resident has a Skin Tear r/t fragile skin. Left lateral ankle/left lower leg. Interventions included - If skin tear occurs, treat per facility protocol and notify MD, family. Review of Resident #2's face sheet shows Resident was admitted to the facility on [DATE] with medical diagnosis of encounter for other orthopedic aftercare. Additional diagnoses included: Weakness, difficulty in walking, chronic obstructive pulmonary disease, excoriation (skin-picking) disorder, subsequent encounter for closed fracture with routine healing, generalized anxiety disorder, major depressive disorder, recurrent, heart failure, and post-traumatic stress disorder. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] documented her BIMS (Brief Inventory of Mental Status) Score as 15 out of 15 which indicated she was cognitively intact. During an observation on 8/09/2026 at 10:55 AM Resident #2 was sitting up in bed. There was a gauze bordered dressing to resident's left lower extremity which was dated 8/08. During an interview on 8/09/2026 at 11:00 AM Resident #2 stated that the wound nurse changed the dressing on her left lower leg on Wednesday and said she would be back on Friday. During an interview on 8/11/2026 at approximately 2:45 PM Physician #2 stated that he did not remember receiving a call regarding Resident #2's wound(s). Review of the policy and procedure titled Documentation, with the last review date of 1/20/2026 read, Policy: Each resident's medical record shall contain an accurate representation of actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation: The following information should be recorded in the resident's clinical record: Abnormal observation from the skin inspection performed such as: edema, redness, drainage, discoloration, and/or other new skin changes. 3) During an observation on 8/09/2026 at 9:35 AM Resident #11 had small red papules on his face and his skin was dry and flakey. Dry skin flakes were observed on the front of his hospital gown. During an interview on 8/10/2026 at 1:55 PM Staff B, LPN stated that if a resident refused a shower or bath, the CNA (Certified Nursing Assistant) was supposed to make 3 attempts to convince the resident to have a shower/bath. The nurse should also check on the resident as to why they refused bathing and to try to convince them to take a bath. She would notify Resident #11's son if the resident refused a bath or shower. During an interview on 8/10/2026 at 1:50 PM Staff V, CNA stated that Resident #11 had refused a bed bath earlier in the day. The process when a resident refused a bath was to document it and try to get the resident to sign that they had refused. When she attempted to have Resident #11 sign the refusal, he had first indicated that he was not able to sign and then that he was not able to read the document. She had not gone back a second time to try to convince him to take a bath. She documented the refusal on a shower sheet, but was not sure if there was documentation in the electronic medical record also. During an interview on 8/10/2026 at 2:00 PM Resident #11 stated that he often preferred a bed bath to a shower. He did not refuse baths. During an interview on 8/10/2026 at approximately 4:00 PM the DON (Director of Nursing) stated that the expectation was for the CNAs to offer residents ADL care - a shower or bath, multiple times. If the resident refused, they were to notify the nurse and document it. If the resident refused a shower or bath multiple times, it should be offered on the next shift. If the resident still refused, the Resident's Representative and the physician should be notified. Review of Resident #11's Care Plan revealed the following: Focus - The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) limited mobility, weakness, dementia, adult failure to thrive. Interventions included - BATHING/SHOWERING: The resident requires assist x1 staff and as necessary. Review of Resident #11's Shower/Bath Sheets from 7/01/2026 through 8/10/2026 revealed there were no documents for 7/01/2026, 7/08/2026, 7/10/2026, 7/13/2026, 7/15/2026, 7/22/2026, 7/24/2026, 7/29/2026, 7/31/2026, 8/03/2026, or 8/05/2026. Review of Resident #11's Task List documentation for ADL - Bathing from 7/01/2026 through 8/10/2026 revealed documentation of Resident #11 refused a bath or a shower on 7/01/2026, 7/03/2026, 7/10/2026, 7/15/2026, and 8/07/2026. Review of Resident #11's Progress Notes from 7/01/2026 through 8/11/2026 revealed that there was no documentation regarding notification to Resident #11's physician or Resident Representative regarding Resident #11's refusal of ADL care/Shower or Bath. Review of the policy and procedure, titled ADL Care and Services, with the last review date of 1/20/2026 read, Standard: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure 7. The resident has the right to refuse any and all ADL care. The refusal of care will be documented in the resident's medical record with appropriate notification including the physician and resident representative. 4)During an observation on 08/09/2026 at 11:05 AM, Resident #28 was lying in bed. There was a gauze dressing to Resident's right wrist, which was dated 08/06/2026. Review of Resident #28's nursing note authored by Staff F, LPN dated 08/06/2026 read, [Certified Nursing Assistant's name] noticed resident had a new skin tear to right wrist (top) and was bleeding this am. Nurse notified, assessed area. Bleeding stopped ,area cleaned and dressed. Review of Resident #28's progress notes showed there was no documentation that the provider was notified of Resident #28's skin tear to the right wrist. During an interview on 08/11/2026 at 8:20 AM Staff A, RN wound care nurse stated, [Resident #28's name] does not have any wounds to my knowledge. Staff are supposed to write any new wounds in the wound care book, so I am notified to go and assess the resident. During an interview on 08/11/2026 at 9:45 AM the Director of Nursing stated that Staff F, LPN should have notified the provider and obtained orders for wound care. 5)During an interview on 08/10/2026 at 9:00 AM, Resident #30's daughter stated, The nurses at the facility don't call me half the time when my Mother falls. I have to find out through the hospice nurses. Review of Resident #30's change in condition note dated 03/06/2026 read, Indicate type of change in condition: Skin. 1. The change in condition, symptoms, or signs observed and evaluated is/are: skin tear. 2. This started on: 03/06/2026. 8. Name of Family/Health Care Agent Notified: [Unit Manager's name]. Date and time notified: 03/06/2026 18:50 [6:50 PM]. Review of Resident #30's change in condition note dated 03/07/2026 read, Indicate type of change in condition: Fall. This started on: 03/07/2026. Name of Family/Healthcare Agent Notified: DON [Director of Nursing]. Date and time notified: 03/07/2026 06:00 [6:00 AM]. Review of Resident #30's nursing progress note dated 03/07/2026 read, CNA notified writer that resident was on the floor in the bathroom. Upon entering the room resident was lying on the floor in the bathroom. Resident was assessed and assisted back into wheelchair. Resident with skin tear to left elbow. DON notified. Plan of care ongoing. Review of Resident #30's change in condition note dated 05/29/2026 read, The change in condition, symptoms, or signs observed and evaluated is/are: Fall. This started on 05/29/2026. 4. Name of Family Member/Responsible Party Notified: [name of hospice]. Date/Time notified: 05/29/2026 11:00. Review of Resident #30's change in condition note dated 07/02/2026 read, The change in condition, symptoms, or signs observed and evaluated is/are: Fall. This started on 07/02/2026. 4. Name of Family Member/Responsible Party Notified: [name of hospice]. Date/Time notified: 07/02/2026 19:10 [7:10 PM]. During an interview on 08/11/2026 at 11:05 AM, the Director of Nursing stated that the family should have been notified for Resident #30's falls. The expectation is for staff to notify the family for changes in condition. Review of policy and procedure titled, Clinical- Change of Resident Condition reviewed 01/20/2026 read, Purpose: To identify changes in Resident condition and communicate the changes to the provider and/or other employees to implement interventions to potentially prevent decline in status and possible re-hospitalization, understanding that not all conditions and declines in medical status are preventable. 4. The provider will be notified of the Resident change in condition with evaluation findings and supporting data (pain evaluation, skin inspection, vital signs, pain level, oxygen saturation, and/or accu-check blood sugar). 8. The resident's family/legal representative should be notified of the change in condition and the current/modified treatment plan as indicated.

Based on interview and record review the facility failed to encode and transmit the resident discharge assessment for 1 of 4 residents, Resident #9, reviewed for minimum data set [MDS] completion. Findings include:Review of Resident #9's EXCEL- SNF(Skilled Nursing Facility) to Hospital Transfer form documented the resident was discharged on 7/15/2026.Review of Resident #9's Minimum Data Set (MDS) assessments did not document a Discharge MDS Assessment for 7/15/2026.During an interview on 8/11/2026 at 8:11 AM, Staff K, Regional MDS Coordinator, stated, [Resident #9's name] 's MDS was not updated because the Facility MDS representative just missed it and the facility does not have a policy they just go by RAI.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards for two (Resident #37 and Resident #2) of ten reviewed for skin issues and one (Resident #43) of three reviewed for feeding tube management.Findings include:During an observation on 8/09/2026 at 10:26 AM Resident #37 was lying in bed on her left side. There was a bandage on her lower right forearm dated 8/7. During an interview on 8/09/2026 at 1:22 PM Resident #37's daughter/Responsible Party stated that she had noticed the bandage on her mother's arm. She presumed it was a skin tear. The facility had not notified her of the injury.During an interview on 8/10/2026 at 1:55 PM Staff B, LPN stated that if a resident had a new skin issue, such as a skin tear, she would assess the resident and try to determine what had happened. If there had been a witness to an event, she would obtain a witness statement. She would notify the family and notify the physician and get wound care orders. If the Wound Care provider needed to see the resident, she would notify them.Review of Resident #37's face sheet revealed she was admitted on [DATE] with medical diagnoses that included metabolic encephalopathy (primary); dysphagia, oropharyngeal phase; weakness; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; aphasia; extended spectrum beta lactamase (ESBL) resistance; cognitive communication deficit; and hypoglycemia, unspecified.Review of Resident #37's Physicians' Orders revealed an order dated 8/04/2026 read, Skin tear: Cleanse area to bilateral arms with wound cleanser, apply TAO (triple-antibiotic ointment) to site and cover bordered gauze QOD (every other day) until healed. every day shift every other day for skin tear. The order was documented as being entered on 8/03/2026 by Staff A, RN as a verbal order from Physician #1.Review of Resident #37's Physicians' Orders revealed an order dated 6/21/2026 that read, Wound care: Right Wrist- cleanse with wound cleanser. Apply TAO to wound bed. Place non-adherent dressing to wound bed and wrap with rolled gauze. Daily and as needed every day shift for Skin Tear.Review of Resident #37's Progress Notes revealed a Nursing Progress Note dated 6/17/2026 read, CNA was getting resident up for the day when she noted a quarter size skin tear to her right wrist. Nurse notified, small amount of bleeding noted. Area cleaned with wound cleaner and then dressing applied. Resident noted no pain to area and no distress noted.Review of Resident #37's Progress Notes from 6/1/2026 through 8/10/2026 revealed no documentation regarding notification to a provider or the Resident Representative regarding Resident #37's wounds/dressings.Review of Resident #37's most recent MDS Assessment, a quarterly assessment dated [DATE] documented no BIMS (Brief Inventory of Mental Status) Score. She required substantial/maximal assistance or was dependent on staff for all self-care activities. She was at risk for pressure ulcers or injuries. She did not have any pressure ulcers/injuries or wounds. She was not receiving wound care. Review of Resident #37's Care Plan revealed the following: Focus - The resident has potential impairment to skin integrity r/t (related to) fragile skin, incontinence, limited mobility / LLE (left lower extremity) Interventions included - Follow facility protocols for treatment of injury. Focus - The resident has a Skin Tear of bilateral arms. Interventions included - If skin tear occurs, treat per facility protocol and notify MD (medical doctor), family.Review of Resident #37's MAR/TAR (Medication Administration Record/Treatment Administration Record) from 8/01/2026 through 8/11/2026 revealed an entry that read, Skin tear: Cleanse area to bilateral arms with wound cleanser, apply TAO (triple antibiotic ointment) to site and cover bordered gauze QOD (every other day) until healed. every day shift every other day for skin tear -Start Date 08/05/2026 0700 (7:00 AM) There was documentation of wound care and application of dressing on 8/05/2026, 8/07/2026, and 8/09/2026.Review of Resident #37's MAR/TAR from 6/01/2026 through 7/31/2026 revealed an entry that read, Wound care: Right Wrist- cleanse with wound cleanser. Apply TAO to wound bed. Place non-adherent dressing to wound bed and wrap with rolled gauze. Daily and as needed every day shift for Skin Tear -Start Date 06/22/2026 0700 -D/C (discontinue) Date 07/08/2026 0839 (8:39 AM) There was documentation of wound care and application of a dressing once daily from 6/22/2026 through 6/29/2026 and 7/01/2026 through 7/07/2026.During an interview on 8/11/2026 at 11:26 AM, Physician #1 stated that he could not recall receiving a call regarding [Resident #37's Name] having a wound. Education may be needed for the nurses regarding wound care and provider notification. If the Wound Care Nurse or a Staff Nurse had received an order for wound care, they should have documented the assessment and the conversation. During an interview on 8/11/2026 at approximately 12:00 PM Staff R, RN stated that if a resident had a skin tear or wound with any bleeding, she would treat it right away to stop the bleeding and document her assessment and the care provided. She would inform the doctor, the Unit Manager and the DON. The family was notified as well. During an interview on 8/11/2026 at 2:24 PM Physician #1 stated that the Wound Care Nurse or Staff Nurses should not enter orders for wound care without confirming the order with a provider. Best Practice would be for the nurse to assess the issue, contact the provider and discuss and confirm an order. As the Medical Director, he was available if other providers could not be reached.During an interview on 8/11/2026 at 3:02 PM, APRN #1 stated that off the top of her head she had not received any calls regarding wounds or treatment orders for [Resident #37's Name] or [Resident #2's Name]. If a resident required wound care and/or required a Wound Care consult, the nurse should contact a provider for an order.During an interview on 8/11/2026 at 1:05 PM Staff A, RN - Wound Care Nurse stated that she had assessed [Resident #37's Name] on 8/04/2026 and discovered that she had wounds on her bilateral forearms with dressings already in place. She had removed the dressings, cleaned the wounds, and applied new dressings. She had entered the wound care orders in the computer. She did not write a progress note or contact a provider to report her findings or confirm the wound care order. She did not contact Resident #37's family regarding the wounds. She routinely addressed wounds and entered orders if they were not already in place or she updated the orders if indicated.During an interview on 8/11/2026 at 1:23 PM, the DON (Director of Nursing) stated that the Wound Care Nurse was expected to notify family and a provider if she identified a new or worsening wound. The facility did not have any standing orders or protocols for wound care or wound care dressings. The Wound Care Nurse or Staff Nurse was expected to contact a provider for any wound care orders.During an interview on 8/11/2026 at 5:28 PM, Staff A, RN - Wound Care Nurse stated that she entered the wound care orders under the name of the resident's PCP (Primary Care Physician), not the Wound Care APRN (Advanced Practice Nurse Practitioner)/Provider. 2) Review of Resident #2's Physicians' Orders from 8/01/2026 through 8/11/2026 revealed an order dated 8/04/2026 that read, Skin Tear: Cleanse skin with wound cleanser of choice. Apply TAO to open area to left lateral ankle and apply non adherent or silicone dressing until healed every day shift for wound care The order was entered by Staff A, RN as a verbal order from Physician #2 on 8/04/2026 at 9:55 AM.Review of Resident #2's Progress Notes from 8/01/2026 through 8/11/2026 revealed there was no documentation regarding a skin tear, notification to family or provider, or treatment orders for wound care.Review of Resident #2's MAR/TAR from 8/01/2026 through 8/11/2026 revealed an entry that read, Skin Tear: Cleanse skin with wound cleanser of choice. Apply TAO to open area to left lateral ankle and apply non adherent or silicone dressing until healed. every day shift for wound care -Start Date 08/05/2026 0700 There was documentation of wound care and dressing application once daily from 8/05/2026 through 8/11/2026.Review of Resident #2's Care Plan revealed the following, Focus - The resident has potential for impairment to skin integrity. Interventions included - Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (medical doctor). Focus -The resident has a Skin Tear r/t (related to) fragile skin. Left lateral ankle/left lower leg. Interventions included - If skin tear occurs, treat per facility protocol and notify MD (medical doctor), family. Review of Resident #2's face sheet shows Resident was admitted to the facility on [DATE] with medical diagnosis of encounter for other orthopedic aftercare. Additional diagnoses, but not limited to included: Weakness, difficulty in walking, chronic obstructive pulmonary disease, excoriation (skin-picking) disorder, subsequent encounter for closed fracture with routine healing, generalized anxiety disorder, major depressive disorder, recurrent, heart failure, and post-traumatic stress disorder. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] documented her BIMS (Brief Inventory of Mental Status) Score as 15 out of 15 which indicated she was cognitively intact.During an observation on 8/09/2026 at 10:55 AM Resident #2 was sitting up in bed. There was a gauze bordered dressing to resident's left lower extremity which was dated 8/08.During an interview on 8/09/2026 at 11:00 AM Resident #2 stated that the wound nurse changed the dressing on her left lower leg on Wednesday and said she would be back on Friday. When the wound nurse came back on Friday she told her that it was fine, that one changed it on Thursday because it only needed to be done three times per week. During an interview on 8/11/2026 at approximately 2:45 PM, Physician #2 stated that he did not remember receiving a call regarding Resident #2's wound(s). It was appropriate for a nurse, after assessing a wound, to make a recommendation for wound care treatment, but they should leave it to the practitioner to make the final treatment decision.Review of the policy and procedure titled Clean/Dry Dressing, with the last review date of 1/20/2026 read, Purpose: To provide guidelines for the application/removal and change of a dry/clean dressing. Procedure: Verify the provider's order for this treatment.Review of the policy and procedure titled Documentation, with the last review date of 1/20/2026 read, Policy: Each resident's medical record shall contain an accurate representation of actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines: 1) Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2) Documentation shall be completed at the time of service but no later than the shift in which the assessment, observation, or care service occurred.3) During an observation on 8/09/2026 at 9:23 AM Resident #43 was sitting up in bed. There was not a feeding pump or any supplies for enteral feeding observed.During an interview on 8/09/2026 at 9:23 AM, Resident #43 stated that she had passed out in the hospital and woke up with a feeding tube. She did not like it. She was taking her medications and Glucerna by mouth and nothing was going through the feeding tube. Review of Resident #43's MAR (Medication Administration Record) revealed documentation of Glucerna being administered enterally four times daily.Review of Resident #43's face sheet revealed she was admitted on [DATE] with medical diagnoses that included nontraumatic intracerebral hemorrhage, intraventricular (primary); unspecified sequelae of cerebral infarction; cerebral edema; type 2 diabetes mellitus without complications; morbid (severe) obesity due to excess calories; paroxysmal atrial fibrillation; gastrostomy status; hypertensive heart disease without heart failure; retention of urine, unspecified; hypothyroidism, unspecifiedReview of Resident #43's Physicians' Orders revealed an order dated 7/20/2026 that read, Consistent Carbohydrates (CCD) diet; Regular texture, Regular/Thin Liquids consistencyReview of Resident #43's Physicians' Orders revealed an order dated 7/10/2026 read, after meals and at bedtime Flush 90mL's of H2O after each bolus feeding, and after meals and at bedtime Bolus 237mL of Glucerna 1.5 when less than 75% eaten at mealsReview of Resident #43's Task List documentation from 7/10/2026 through 8/10/2026 related to percentage of meals eaten for the past 30 days revealed 11 instances of Resident #43 consuming less than 76% of a meal and 6 instances of Resident #43 refusing a meal.Review of Resident #43's MAR/TAR from 6/01/2026 through 8/09/2026 revealed an entry that read, Enteral Feed Order: after meals and at bedtime Bolus 237mL of Glucerna 1.5 when less than 75% eaten at meals Start Date-07/10/2026 1800 There was documentation of administration four times daily 8/01/2026 through 8/08/2026, twice on 7/10/2026, four times daily from 7/11/2026 through 7/26/2026, two times on 7/27/2026, three times on 7/28/2026, and four times on 7/29/206 and 7/30/2026, and three times on 7/31/2026. Review of Resident #43's Progress Notes revealed a Nutrition Note dated 7/09/2026 that read, Resident receives Glucerna 1.5 56 ml's /hr. x 20 hrs. (milliliters per hour times 20 hours) via feeding tube, per pump. Tube flushed with 42 ml's H2O/hr. x 20 hrs. Resident receives CCD (controlled carbohydrate diet), Mech. (mechanical) Soft diet, intake varies, approximate 60% average meals eaten, per meal intake record. Weight 231#, above IBWR120# +/- 10%.BMI 39.6. Skin issue R buttock. Current labs unavailable for review. Assessed nutritional needs: Kcals 1682 25 Kcals/Kg. adj.wt.,Pro.67 1 gm/Kg. adj. wt., Fluid 1 ml/Kcal. Recommend Glucerna 1.5 56 ml's/hr. x 20 hrs be discontinued. Recommend H2O flush 42 ml's/hr. x 20 hrs be discontinued. Recommend Glucerna 1.5 237 ml's bolus when <75% meals eaten. Recommend tube be flushed with 90 ml's H2O before and after each bolus feeding. Monitor intake/weight/skin issue/tolerance to bolus feedings and H2O flushes with intervention PRN.Review of Resident #43's most recent MDS Assessment, an end of Part A assessment dated [DATE] documented her BIMS Score as 15 out of 15 which indicated she was cognitively intact. She required supervision or touching assistance for eating. She had a feeding tube; she required a mechanically altered diet; she required a therapeutic diet.Review of Resident #43's care plan documented, Focus - The resident requires tube feeding. Interventions included - The resident is dependent with tube feeding and water flushes. See MD (Medical Doctor) orders for current feeding orders., The resident has nutritional problem r/t (related to) DYSPHAGIA, GASTRO-ESOPHAGEAL REFLUX, DMII, CVAInterventions included - Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD (Registered Dietitian) to evaluate and make diet change recommendations PRN (as needed).During an interview on 8/10/2026 at approximately 1:30 PM Staff B, LPN stated that residents who had G tubes, but were able to take medications and/or food and fluids orally and were being tapered off of their tube feedings, she would confirm with the CNAs the percentage of meals consumed. She would either check with the CNAs or confirm the documentation in PCC (the electronic medical record). If the resident was consuming over the required amount for a week, she would contact the provider to recommend having the G-tube removed. During an interview at approximately 9:15 AM Staff B, LPN stated that related to Resident #43's ordered enteral feedings, for the majority of the time she would ask Resident #43 how much of her meal she had eaten to know whether she required the ordered Glucerna. Resident #43 would drink the Glucerna, so she would administer it orally [versus the order route of enterally].During an interview on 8/11/2026 at 9:50 AM the DON (Director of Nursing) stated that medications and feedings were expected to be documented by the route they were being administered. If the order was for enteral administration the feeding should be given enterally, not orally. If the resident preferred to take the feeding orally, the physician should be notified, and the order should be updated.During an interview on 8/11/2026 at 2:45 PM the RD (Registered Dietitian) stated that she had recommended bolus feeding with a flush before and after the bolus if she was not eating 75% of her meals. Glucerna was a safety measure to make sure Resident #43 got enough nutrition and did not lose weight. She had ordered it as an enteral bolus because some residents did not want to drink that much and it would be for their comfort. If the resident wanted to drink the Glucerna that would be better. She was not aware that Resident #43 was drinking the Glucerna, no one had contacted her. If the resident wanted the feeding tube removed, she would discuss it with the physician.Review of the policy and procedure titled, Medication Administration, with the last review date of 1/20/2026 read, Purpose: To administer medications as per provider's order in accordance with regulatory guidelines and practice standards. Policy: Licensed or qualified personnel shall administer medication per their licensure scope of practice following the providers order. Guidelines for medication administration: Read orders to ensure the information is clear and accurate. Clarify questions with the Charge Nurse or the provider as needed. Observe the rights of medication administration - right resident, right medicine, right time, right dose, write route, write documentation.

Based on interview, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for haircuts for 1 of 3 residents, Resident #7 reviewed for ADL care. Findings include: During an observation on 8/09/2026 at 10:16 AM Resident #7 was resting in bed. Resident #7's hair extended beyond his ears. During an interview on 8/09/2026 at 10:16 AM Resident #7 stated, I would like to get a haircut. They have never offered to do that for me.Review of Resident #7 Care Plan dated 6/16/2026 documented, Focus: The resident has an ADL self-care performance deficit r/t weakness, limited mobility, confusion, compression fracture, h/o falls. During an interview on 8/11/2026 at 9:30 AM Director of Nursing stated that the facility does not have anything in writing stating that [Resident #7's name] has been receiving or refusing the haircuts. Reviewed Policy and Procedure: Clinical Activities of Daily Living (ADL's) Effective Date 4/1/2022 Revision Date 11/11/2025 states Purpose: To ensure resident's needs are met in a manner that promotes their quality of life, resident rights, preferences, and independence. Procedure: 2. The facility shall provide care and services for the following activities of daily living as needed based on the individual care plan of each resident: A. Hygiene: bathing, dressing, grooming, and oral care

Based on interview, observation and record review, the facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds (Resident #113, Resident #21 and Resident #28). Findings Include: 1)During an observation on 08/09/2026 at 11:05 AM, Resident #28 was lying in bed. There was a gauze dressing to Resident's right wrist, which was dated 08/06/2026. Review of Resident #28's nursing note, authored by Staff F, LPN (Licensed Practical Nurse) dated 08/06/2026 read, [Certified Nursing Assistant's name] noticed resident had a new skin tear to right wrist (top) and was bleeding this am. Nurse notified assessed area. Bleeding stopped area cleaned and dressed. Review of Resident #28's physician orders revealed there were no orders for wound care to the right wrist. During an interview on 08/11/2026 at 8:20 AM Staff A, RN (Registered Nurse) wound care nurse stated, [Resident #28's name] does not have any wounds to my knowledge. When a resident gets a skin tear, the nurse should take care of the skin tear, recover the skin back over, cleanse it, and dress it. They should notify the physician, the family, and put new orders in. During an interview on 08/11/2026 at 9:45 AM the Director of Nursing (DON) stated that [Resident #28's Name] does not have orders for wound care to right wrist. The DON stated that Staff F, LPN should have notified the provider and obtained orders for wound care. 2.) During observation of Resident #21 on 08/09/2026 at 10:10AM Resident had an island dressing on Right knee with no date or initials. During an interview with DON on 08/11/2026 at 8:20 AM stated, Yes, I expect the dressings to be dated. We have a full-time wound care nurse. During an interview with the Wound Care Nurse, Staff A, RN (registered nurse) on 08/11/2026 at 9:33AM it is her practice to date and initial every dressing change. She works Monday thru Friday and the nurse on the cart is responsible to do the daily dressing changes on the weekends and the PRN dressing changes. Review of Treatment Administration Record for August 2026 read, Treatment as follows: R knee surgical site cleanse with wound cleanser, apply long island dressing. every day shift for Wound Care Observe changes in drainage, pain, or s/sx (signs/symptoms) of infection. Notify Provider as appropriate 07/30/2026. Review of facility Policy and Procedure titled, Clinical-Clean/Dry Dressing, last revision 01/20/2026 read, Purpose: To provide guidelines for the application/removal and change of a dry/clean dressing. Procedure, Affix and prepare tape/label with date and initials. 3)During an observation on 8/9/2026 at 12:34 PM Resident #113 was lying in bed there was a dressing dated 8/6 and a white pain patch on her left arm dated 8/6/2026. Review of Resident #113 's physician order dated 8/1/2026 read, Cleanse left arm with wound cleanser and apply xeroform and honey gel and place border gauze everyday shift for skin tear. Review of Resident of Resident #113's physician order dated 8/1/2026 read, Aspercreme Lidocaine Patch 4% (Lidocaine) apply to left shoulder topically Morning/Night for Apply to left hip and remove at bedtime. During an interview on 8/11/2026 at 9:35 AM Staff A Wound Care Nurse stated, I cover skin tears. Over the weekend the cart nurse will have the knowledge to treat them. I was not familiar with [Resident #113's name] skin tear wound dressing orders. I have a wound log on every unit. Monday I round on every unit for follow up the information is not always convene to me. I will see the nurse and she sometimes will tell me and then it should be put in into the system and make sure I round. Normally change every day or every other day depending on the severity. I eye it depending on drainage if superficial could be treated every other day. I myself need to be aware and if I am not I have no way of knowing if its not on my wound log. I would not have the Knowledge to know it needs to be changed out. Wound care should be done as order. This is one I was not familiar with. During an interview on 8/11/2026 at 10:15 AM with the Director of Nursing stated, Dressings and treatments should be done however ordered. A check mark in the treatment record means completed. Nurses are to accurately document care provided. During an interview on 8/11/2026 at approximately 3:15 PM with Staff B Licensed Practical (LPN), stated, Her [Resident #113's name] patch should be removed every day and put a new one. Review of the facility policy and procedure titled Clinical-Clean/Dry Dressing with a last review date of 1/20/2026 read, Verify the provider's order for this treatment.

Based on interview, observation and record review the facility failed to provide treatment and services for the care of one out of five residents reviewed for indwelling urinary catheter.Findings Include:During observation of Resident #60 on 08/09/2026 at 9:15 AM Foley tubing had cream colored sediment residing along length of the tubing. During observation of Resident #60 on 08/11/2026 at 10:21AM Foley line sediment was observed to be unchanged in appearance with cream colored sediment along the length of the tubing. During an interview with Staff N, CNA on 08/11/2026 10:31 AM she stated Hospice comes on Fridays. If I noticed something wrong with his foley when I was emptying it I would let the nurse know.During interview via phone with Haven Hospice Director of Clinical Operation, on 08/11/2026 at 11:53AM stated, Our last visit was 08/07/2026. The aid documented that she performed bath, shampoo, shave and emptied the foley. If they found anything new or the Resident made any complaints or had a request the aid would let the RN(registered nurse) for Hospice know and the floor nurse after care was provided.During an interview with the ADON(Assistant Director of Nursing) Infection Control Nurse on 08/11/2026 at 12:30PM she stated that [Resident #60's Name] foley catheter tubing should be changed from the way it looks. The problem is he does not have a formal order for changing the tubing every 30 days right now it is just PRN (pro re nata).During interview with DON (Director of Nursing)on 08/12/2026 1:53 PM she stated a PRN foley change would need to be done if there was leakage, blockage or it had sediment that could not be flushed out. Review of Resident #60's Physician Orders revealed ,Foley Care every shift 06/15/2026. Urinary Catheter: Irrigate with 60cc (cubic centimeters) normal saline for blockage, increased sediment, or decreased output. every 6 hours as needed Notify physician of any abnormal observation from baseline 05/22/2026.Review of facility Policy and Procedure, titled, Clinical-Indwelling Urinary Catheter, Last revised on 01/20/2026 read, Purpose: To minimize complications associated with indwelling urinary catheter use. Procedure: 5. Changing indwelling catheters or drainage [NAME] routinely and at fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage based based on clinical indications, obstruction, or when the closed system is compromised at the discretion of the medical provider. 8. Observe the resident routinely for complications related to urinary catheter use. Report new complications to the provider as indicated.

Based on interview and record review the facility failed to complete dialysis communication sheet for 1 (Resident #6) of 2 residents reviewed for dialysis. Findings include: Review of Resident #6 physician order dated 5/20/2026 read, Dialysis Treatment Center Name: [Name and Phone Number of Third Party Dialysis Provider] Days/Schedule: TU/TH/SA [Tuesday/Thursday/Saturday] Pick up time:0700 Chair Time:0730 Transport via Wheelchair every day shift every Tue, Thu, Sat for Dialysis Information. Review of Resident #6 Dialysis Communication Forms facility to complete upon resident's return from dialysis section was not completed on 8/8/2026, 8/6/2026, 8/4/2026, 8/1/2026, and 7/28/2026. No other communication sheets were provided prior to 7/28/2026. During an interview on 8/11/2026 at 12:50 PM Staff G Licensed Practical Nurse (LPN) stated, We do an assessment for him [Resident #6] and fill out the communication sheets for him before he goes to dialysis and upon return. During an interview on 8/12/2026 at 8:32 AM Director of Nursing (DON) stated, I expect the staff to complete the communication sheets completely. when asked about the progress notes stated it would be on the communication sheet. No other communications sheets provided. During an interview on 8/12/2026 at 9:42 AM with the DON stated no other communication sheets provided. During an interview on 8/12/2026 at 11:10 AM with Staff D, LPN, stated, Normally we will fill out the dialysis book before leaving and upon his [Resident #6] return we would have to take his vitals and fill out the dialysis communication book. Review of the facility policy and procedure titled Clinical Dialysis Management with a last review date 1/20/2026 read, 2. Facility personnel will provide information that is useful or necessary for the care of the resident to the dialysis center as needed.

Based on observation, interview, and record review the facility failed to maintain the exterior waste properly. Finding include:During an observation on 8/9/2026 at 9:41 AM of the exterior dumpster area with Staff T the lid of dumpster was open. Inside there were clear plastic bags. Next to the dumpster there is a grease trap that had dark buildup and liquid pooling outward from the base of the grease container across the concrete pad. There was loose debris, trash fragments, paper clutter accumulated directly around the base.During an interview on 8/9/2026 at 9:41 AM with Staff T Lead [NAME] stated, Dumpster lid should be closed at all times. I am not sure who is responsible for cleaning the grease trap.During an interview on 8/11/2026 at 1:20 PM with Assistant Dietary Manager stated, The garbage container lid should always be closed. The grease trap I do no know who maintains it no one has ever told us to clean it.During an interview on 8/11/2026 at 2:16PM with the Administrator stated, The dumpster lid should be closed at all times. I will go look at the grease trap and speak to maintenance.During an interview on 8/11/2026 at 3:12 PM with Maintenance Director stated, The area needs to be clean looks like it has some sort of spillage.Review of the facility policy and procedure titled Dietary Department Dumpster and Trash Management Policy with a last review date 1/20/2026 read, Purpose: To ensure safe, sanitary, and regulatory-compliant handling and disposal of all dietary waste in accordance with infection control standards and guidelines from Centers for Medicare & Medicaid Services, Occupational Safety and Health Administration, and Centers for Disease Control and Prevention. Policy Statement: All dietary waste must be handled, stored, and disposed of in a manner that prevents contamination, odors, pest infestation, and safety hazards for residents, staff, and visitors. Procedures: 4. Dumpster Use: Dumpster lids must remain closed at all times when not in use.5. Cleaning & Sanitation. Dumpster areas must be: Clean and free of debris. Washed down routinely (recommended weekly or as needed). Immediate cleanup for: spills, leaks, loose trash. 9. Compliance & Monitoring: Dietary Manager or designee will: Conduct routine inspections of the dumpster area. Ensure compliance with sanitation standards. Deficiencies will require immediate corrective action.

Based on observation, interview and record review, the facility failed to ensure complete and accurate documentation in the medical record for activities of daily living care for 1 of 3 residents reviewed (Resident #11), and documentation on the treatment administration record for 3 of 10 residents reviewed for skin conditions (Resident #113, Resident #21, Resident #3). Findings Include: 1) Review of Resident #3's physician order dated 06/20/2026 read, Wound Care: RLE [right lower extremity]- cleanse with wound cleanser. Apply A&D ointment to peri wound. ABD [abdominal] pad to wound bed. Wrap with Ace bandage. Daily and as needed. every day shift for Weeping. Review of Resident #3's TAR (Treatment Administration Record) for July 2026 showed wound care for right lower extremity was not documented on July 10, 2026, July 12, 2026, July 21, 2026 and July 30, 2026. Review of Resident #3's physician order dated 07/07/2026 read, Wound Care: LLE [left lower extremity] (outer) Cleanse with wound cleanser. Apply ointment to peri wound. Collagen sheet to wound bed secure with ABD pad. Wrap with Ace bandage. QOD [every other day] and as needed. Review of Resident #3's TAR for July 2026 showed wound care for left lower extremity was not documented on July 10, 2026 and July 12, 2026. During an interview on 08/12/2026 at 9:03 AM, Staff L, LPN [licensed practical nurse] stated, I completed the wound care, I am not sure why it didn't get documented. 2.) During observation of Resident #21 on 08/09/2026 at 10:10AM Resident had no compression socks on bilateral lower extremities. During an interview with DON on 08/11/2026 at 2:10PM stated, All Doctors orders are expected to be carried out and refusals charted. Review of Residnet #21's Physician Orders documented, Compression stockings to BLE every day shift 07/22/2026. 3) During an observation on 8/9/2026 at 12:34 PM Resident #113 was lying in bed there was a dressing dated 8/6 and the patch on her left arm dated 8/6/2026. Review of Resident #113's physician order dated 8/1/2026 read, Cleanse left arm with wound cleanser and apply xeroform and honey gel and place border gauze everyday shift for skin tear. Review of Resident #113 Treatment Administration Record for the month of August 2026 documented dressing was completed on 8/8/2026. Review of Resident of Resident #113's physician order dated 8/1/2026 read, Aspercreme Lidocaine Patch 4% (Lidocaine) apply to left shoulder topically Morning/Night for Apply to left hip and remove at bedtime. Review of Resident #113 's Treatment Administration Record for the month of August 2026 documented patches were applied and removed on 8/7/2026 and 8/8/2026. During an interview on 8/11/2026 at 9:35 AM Staff A Wound Care Nurse stated, I cover skin tears. Over the weekend the cart nurse will have the knowledge to treat them. I was not familiar with [Resident #113's name] skin tear wound dressing orders. I have a wound log on every unit. Monday I round on every unit for follow up the information is not always convene to me. I will see the nurse and she sometimes will tell me and then it should be put in into the system and make sure I round. Normally change every day or every other day depending on the severity. I eye it depending on drainage if superficial could be treated every other day. I myself need to be aware and if I am not I have no way of knowing if its not on my wound log. I would not have the Knowledge to know it needs to be changed out. Wound care should be done as order. This is one I was not familiar with. During an interview on 8/11/2026 at 10:15 AM with the Director of Nursing (DON) dressing should be done however order. A check mark in the MAR means completed. Nurses are to accurately document care provided. During an interview on 8/11/2026 at approximately 3:15 PM with Staff B Licensed Practical (LPN), stated, That night I took the patch off her shoulder. I don't know. During an interview on 8/12/2026 at 8:41 AM with Staff I, LPN, stated, I do not recall. A check mark means it was completed. 4.) During an observation on 8/09/2026 at 9:35 AM Resident #11 had small red papules on his face and his skin was dry and flakey. Dry flakes of skin were observed on the front of his hospital gown. Review of Resident #11's Shower/Bath Sheets from 7/01/2026 through 8/10/2026 revealed there were no documents for 7/01/2026, 7/08/2026, 7/10/2026, 7/13/2026, 7/15/2026, 7/22/2026, 7/24/2026, 7/29/2026, 7/31/2026, 8/03/2026, or 8/05/2026. Review of Resident #11's Task List documentation for ADL - Bathing from 7/01/2026 through 8/10/2026 revealed documentation inconsistent with documentation on the printed Shower/Bath Sheets on 7/03/2026, 8/07/2026, and 8/102026. There was documentation of Resident #11 refused a bath or a shower on 7/01/2026, 7/03/2026, 7/10/2026, 7/15/2026, and 8/07/2026. There was nothing documented on 7/08/2026 or 8/10/2026. Review of Resident #11's Progress Notes from 7/01/2026 through 8/11/2026 revealed that there was no documentation regarding notification to Resident #11's physician or Resident Representative regarding Resident #11's refusal of ADL care/Shower or Bath. During an interview on 8/10/2026 at 1:55 PM Staff B, LPN stated that if a resident refused a shower or bath, the CNA was supposed to make 3 attempts to convince the resident to have a shower/bath and document the outcome. The nurse should also check on the resident as to why they refused bathing and to try to convince them to take a bath. The nurse was supposed to sign the shower sheet. During an interview on 8/10/2026 at 1:50 PM Staff V, CNA stated that [Resident #11's Name] had refused a bed bath earlier in the day. The process when a resident refused a bath was to document it and try to get the resident to sign that they had refused. When she attempted to have [Resident #11's name] sign the refusal, he had first indicated that he was not able to sign and then that he was not able to read the document. She had not gone back a second time to try to convince him to take a bath. She documented the refusal on a shower sheet but was not sure if there was documentation in the electronic medical record also. During an interview on 8/10/2026 at 2:00 PM Resident #11 stated that he often preferred a bed bath to a shower. He did not refuse baths. During an interview on 8/10/2026 at approximately 4:00 PM the DON (Director of Nursing) stated that the expectation was for the CNAs (Certified Nursing Assistants) to offer residents ADL care - a shower or bath, multiple times. If the resident refused, they were to notify the nurse and document it. The documentation on the Shower Sheets should match what was documented in [the electronic medical record]. Review of the policy and procedure titled, ADL Care and Services, with the last review date of 1/20/2026 read, Standard: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Guideline: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the policy and procedure titled, Documentation, with the last review date of 1/20/2026 read, Policy: Each resident's medical record shall contain an accurate representation of actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines: 1) Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2) Documentation shall be completed at the time of service but no later than the shift in which the assessment, observation, or care service occurred. 6) Contradictory information may be clarified by a new entry in the medical record. a. Date and time the entry. b. Provide sufficient details to support that the current information is accurate. c. Sign each entry with the name and credentials.

Based on observation, interview and record review the facility failed to perform hand hygiene for 1 (Resident #115) of 10 residents reviewed for skin conditions, failed to perform hand hygiene for 1 (Resident #35) of 9 medication observations, failed to donned appropriate personal protective equipment for 2 (Resident #35 and Resident #92) of 4 residents review for enhanced barrier precautions, and failed to clean medical equipment and perform hand hygiene during dining. Findings include: 1) During an observation on 8/9/2026 at 11:24 AM Staff J Certified Nursing Assistant grabbed a pink tumbler from Resident #20's table and filled with the tumbler with apple juice. Staff J returned to the table and placed down the tumbler. Staff J return to the drink cart and poured cranberry juice and delivered the cup to Resident #20. Staff J without hand hygiene proceed to the next table and asked Resident #26 whom was accompanied by his wife and Resident # 72 what they would like to drink. Staff J return to the drink cart and poured drinks. Staff V ,CNA assisted Staff J ,CNA to deliver drinks to the table. Staff J without performing hand hygiene proceed to Resident #52's table and served him cream in his coffee cup. 2)During an observation on 8/11/2026 at 9:19 AM, Staff A Wound Care Nurse and the Assistant Director of Nursing (ADON) were standing at the treatment cart. Staff A removed her gloves to don gown and without hand hygiene donned a gown and a new pair of gloves to prepare the supplies needed. Staff A Wound Care Nurse entered Resident #115's room, adjusted the bed using the bed remote. Staff A using the same gloves removed the dressing on Resident #115 's right groin area. Staff A then removed the gloves and without hand hygiene donned a new set of gloves. Staff A cleaned the wound and removed the gloves. Staff A did not perform hand hygiene and don new pair of gloves. Staff A packed the wound and changed gloves without performing hand hygiene, donned new gloves and applied a new dressing. During an interview on 8/11/2026 at 9:30 AM with the ADON stated, More hand hygiene should have been done in between glove changes. During an interview on 8/11/2026 at 9:46 AM with Staff A Wound Care Nurse stated, I should have done hand hygiene in between changing my gloves. During an interview on 8/12/2026 at 9:42 AM with the Director of Nursing stated, Staff should perform hand hygiene every time she changes her gloves. The staff should perform hand hygiene in between each resident interaction. 3) During the observation of the preparation of oral medications on 8/11/2026 at 9:04 AM, a multivitamin tablet was dropped onto the top of the medication cart. Staff B, LPN put on gloves, without performing hand hygiene, picked up the medication and placed it in the medication cup. Staff B, LPN removed and discarded her gloves without performing hand hygiene. She added additional oral medications to the pill cup and proceeded to administer the medications to Resident #35. 4) During an observation on 8/11/2026 at 9:34 AM Staff B, LPN (Licensed Practical Nurse), obtained Resident #8's blood pressure without cleaning the blood pressure cuff that was previously used on another resident. She failed to perform hand hygiene after obtaining the blood pressure/before preparing and administering oral medications. During an interview on 8/11/2026 at approximately 10:00 AM Staff B, LPN stated that the top of the medication cart was not a clean surface and she should have discarded the multivitamin that dropped onto the top of the medication cart. She believed the policy for cleaning resident-care equipment was to clean it between residents. She confirmed that she had used the blood pressure cuff on another resident prior to taking Resident #8's blood pressure and had not cleaned it in between. During an interview on 8/11/2026 at 9:50 AM the DON (Director of Nursing) stated the expectation for nurses administering medications was that if a pill was dropped on top of the medication cart it should be discarded. Hand hygiene was required before preparing medications for administration, and after administration to each resident. Equipment, such as blood pressure cuffs, were to be cleaned after each use/between residents. 5) During an observation on 8/11/2026 at 8:55 AM Staff C, LPN disconnected Resident #92's IV line, attached a syringe of 10ml of normal saline, flushed the line, removed the syringe and attached a new cap. She was not wearing a gown during the procedure. During an interview on 8/11/2026 at approximately 1:10 PM Staff C, LPN stated that Enhanced Barrier Precautions (EBP) applied to residents with IVs. The EBP were to provide an extra layer of protection for the residents. When providing direct care for residents on EBP, staff were to use gowns, gloves, and sometimes a mask. During an observation on 8/12/2026 at 7:35 AM Staff D, LPN accessed Resident #92's PICC (peripherally inserted central catheter) line, located in her right upper arm. She flushed with 10 milliliters of normal saline and attached the intravenous antibiotic infusion. She was not wearing a gown during the procedure. During an interview on 8/12/2026 at 7:40 AM Staff D, LPN stated that Enhanced Barrier Precautions (EBP) were to protect residents from multidrug-resistant organisms. For residents who were on EBP, staff were supposed to wear personal protective equipment (PPE) when performing direct care. She should have worn a gown when she was administering Resident #92's IV antibiotics because Resident #92 was on EBP. During an interview on 8/11/2026 at 11:05 AM the DON stated that when residents were on EBP the staff needed to wear appropriate PPE, at least a gown and gloves, when providing direct care, which would include administering or discontinuing IV medications or flushing a PICC line. Review of Resident #92's Physician Order revealed an order dated 7/31/2026 that read, Enhanced Barrier Precautions – PICC line every shift 6) During an observation on 8/12/2026 at 9:20 AM Staff E, RT (Respiratory Therapist) performed tracheostomy care for Resident #73. She donned a pair of gloves and a mask. She removed her gloves after setting up the supplies and donned a clean pair. She did not wear a gown during the procedure. During an interview on 8/12/2026 at 9:27 AM Staff E, RT stated that she did not wear a gown while providing tracheostomy care for Resident #73. She did not believe she was required to wear a gown unless she was performing deep suctioning. During an interview on 8/12/2026 at 9:32 AM the DON stated that the expectation for a resident on EBP was that all staff would wear a gown, gloves, and a mask if indicated, while performing direct patient care. For Resident #73, while receiving tracheostomy care, staff should wear a gown, gloves, and a mask. Review of Resident #73's Physicians' Orders revealed an order dated 3/12/2026 read, Enhanced Barrier Precautions-[NAME] tube (a soft, flexible silicone device placed into a neck stoma after a person has their larynx (voice box) removed) every shift Review of the facility policy and procedure titled Hand Hygiene with a last review date 1/20/2026 read, Purpose: This facility requires employees to use a acceptable infection control practices which includes hand hygiene when it is indicated. Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: Situations that require hand hygiene include, but not limited to: Before and after direct resident contact. After removing gloves or aprons. Review of the facility policy and procedure titled Clinical-Clean/Dry Dressing with a last review date 1/20/2026 read, Perform hand hygiene. Review of the Policy and Procedure titled Enhanced Barrier Precautions (EBP) with the last review date of 1/20/2026 read, Purpose: To ensure compliance with regulations and practice standards in the facility's effort to decrease transmission of multidrug-resistant organisms (MDRO). Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resident organisms by utilizing Person Protective Equipment (PPE) during high contact resident care activities. Procedure: 1. Enhanced Barrier Precautions (EBP) are used for resident with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be colonized with MDRO. 6. Indwelling Medical Devices include the following: a. Central lines d. Tracheostomies 9. Appropriate PPE for EBP would include: a. Gown b. Gloves 10. Employees should wear appropriate PPE when performing the following duties for residents requiring EBP: j. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Review of the policy and procedure titled, Infection Control – Clinical Equipment Cleaning, with the last review date of 1/20/2026 read, Standard: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. Guideline: 2. Non-critical resident-care items are those that come in contact with intact skin but not mucous membranes. A. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. B. Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). 3. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 5. Durable medical equipment (DME) is cleaned and disinfected before re-use by another resident. Review of the policy and procedure titled, linical – Medication Administration, with the last review date of 1/20/2026 read, Purpose: To administer medications as per provider's orders and in accordance with regulatory guidelines practice standards. Preparation: E.) The top of the medication cart should be kept free of any hazardous material including medications. Infection Control: A.) Perform hand hygiene prior to beginning med pass; after direct contact with a resident or if hands become visibly soiled; before and after administering meds. C.) Avoid touching medications with hands.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate wound care for 2 of 4 residents reviewed for skin and wound care, Residents #23 and #49, and 1 of 8 residents reviewed for medication management, Resident #65. Findings include: 1) During an observation on 4/7/2025 at 10:19 AM, Resident #49 was sitting in a chair, dressed in street clothes. The resident had one dressing on his abdomen with drainage, which was dated 4/4, one dressing on his wrist, of dry gauze, dated 4/4, one dressing on his upper thigh with no apparent drainage, under an elastic wrap, with no date visible, and one dressing on his lower back, which could not be fully observed. During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his wounds were last cleaned on Friday, 4/4/2025, with their dressings changed at that time. Review of Resident #49's Admission Assessment, dated 3/24/2025, documented the following information in the wound/skin section: a surgical incision on the right side of the abdomen; a G-tube (gastrostomy tube) on the left side of the abdomen; and graft sites on the left wrist, front of right thigh, and front of left thigh. There was no information documented regarding a wound or a dressing on Resident #49's lower back/sacrum/coccyx. Review of Resident #49's physician order dated 3/25/2025 read, Unwrap right thigh daily and monitor graft site for any s/s [signs and symptoms] of infection. Do not remove protective dressing that is stapled in place. Place new wound veil over graft site, secure with rolled gauze and ace wrap every day shift for wound care. Review of Resident #49's physician order dated 3/25/2025 read, Apply A&D [Vitamin A and D] ointment to healed left thigh graft site daily every day shift for wound care. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse left wrist wound with wound cleanser, apply bacitracin and non-adherent dressing, secure with rolled gauze daily & PRN [and as needed] as needed for soiled or dislodged. Review of Resident #49's physician order dated 3/25/2025 read, Cleanse abd [abdominal] wound with wound cleanser, apply bacitracin ointment to wound bed, cover with wound veil and dry dressing daily every day shift for wound care. Review of Resident 49's Treatment Administration Record for April 2025 showed staff initials for applying A&D ointment, cleansing abdominal and left wrist wound, unwrapping right thigh on 4/5/2025 and 4/6/2025. During an observation on 4/8/2025 at 4:10 PM, Resident #49 had a large transparent dressing on his lower back which had a date of 3/2x/25 (the 2nd digit of the day could not be clearly observed). During an interview on 4/8/2025 at 4:15 PM, Staff H, Licensed Practical Nurse (LPN), stated she was not aware of a dressing on Resident #49's sacrum/coccyx. During an interview on 4/8/2025 at 4:22 PM, the Director of Nursing (DON) stated that her expectation was that when a resident was admitted , the nurse in the facility would complete a head-to-toe assessment of each resident and document all wounds and dressings. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated, On Saturdays and Sundays, the nurse from the other hall works 7:00 AM to 3:00 PM and does wound care for the residents on my hall. The nurse let me know what wound care was completed, and I documented the wound care and dressing changes. I did not recall if I checked to see that [Resident #49's name] wound care had been completed on Saturday 4/5/25 or Sunday 4/6/25. During an interview on 4/9/2025 at 10:08 AM, Staff G, Registered Nurse (RN), Unit Manager, stated, On new admissions, the expectation is that a head-to-toe skin assessment is completed, and all wounds and dressings are documented. The dressing on [Resident #49's name] lower back should either have been removed or orders should have been obtained. If there are orders for daily wound care and/or dressing changes, it should be done daily. Review of the facility policy and procedure titled Dressing- Dry/Clean with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry/clean dressings. General guidelines: 1. Verify that there is a physician's order for this procedure . 3. Check the treatment record . Procedure . 11. Label tape or dressing with date, time and initials. Place on clean field . 19. Apply the ordered dressing . Label with date and initials on top of dressing. 46523 2) During an observation on 4/7/2025 at 9:50 AM, Resident #23 was sitting in her wheelchair with a dressing on her left knee. The dressing had dried dark substance, and the dressing had no date or initials. During an interview on 4/7/2025 at 9:50 AM, Resident #23 stated, I bumped my knee that is why I have this dressing. During an observation on 4/8/2025 at 4:20 PM, Resident #23 was sitting near the nursing station in her electric wheelchair. The dressing on her left knee had dried dark substance, and the dressing had no date or initials. Review of Resident #23's physician order dated 12/16/2024 read, Skin tear to Left knee: Cleanse with wound cleanse of choice pat dry apply TAO [triple-antibiotic ointment] and cover with dry dressing every day shift for TX (treatment). During an interview on 4/9/2025 at 4:30 PM, the Director of Nursing stated, Staff should date and initial all dressings. 3) Review of Resident #65's physician order dated 1/18/2025 read, Carvedilol Oral Tablet 3.125 MG [Milligram] (Carvedilol), Give 1 tablet by mouth two times a day related to essential (primary) hypertension. Review of Resident #65's Medication Administration Record (MAR) for March 2025 for administration of Carvedilol showed staff documented code 11 on 3/5/2025, 3/7/2025, 3/14/2025, 3/15/2025, 3/24/2025 and 3/28/2025 at 9:00 AM, and documented code 11 on 3/5/2025, 3/7/2025, 3/10/2025, 3/11/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/24/2025, 3/30/2025 at 5:00 PM. Code 11 stands for held per parameters. Review of Resident #65's MAR for April 2025 for administration of Carvedilol showed staff documented code 11 on 4/7/2025 at 9:00 AM and on 4/8/2025 at 5:00 PM. During an interview on 4/9/2025 at 1:10 PM, the DON stated, [Resident #65's name] Carvedilol did not have parameters in place and the nurses were holding the medication. The nurses should follow the doctors' orders when giving medication or call the provider to clarify any questions. During an interview on 4/10/2025 at 4:16 PM, the Advance Practice Registered Nurse #2 stated, Staff always call me and notify me when they will be holding a medication for [Resident #65's name]. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/21/2025 read, General Guidelines: 3. Medications are administered in accordance with prescriber orders, and current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards for storing respiratory therapy equipment for 3 of 4 residents reviewed for respiratory services (Residents #45, #51, and #87), for 3 of 6 residents reviewed for enhanced barrier precautions (Residents #6, #93, #114), for 1 of 4 residents reviewed for skin conditions (Resident #2), for 4 of 5 residents reviewed for medication administration (Residents #61, #116, #321 and #324) to help prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was a passive nebulizer mask and mouthpiece on top of the resident's desk across from his bed, which was not bagged (Photographic evidence obtained). Review of Resident #45's physician order dated 4/1/2025 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (milligrams per 3 milliliters). Directions: 3 ml inhale orally via nebulizer every 6 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. During an interview on 4/9/2025 at 4:06 PM, the Director of Nursing (DON) stated, The mouthpiece mask of a nebulizer and tubing should be bagged when not in use. 2) During an observation on 4/8/2025 at 4:47 PM, Staff C, Certified Nursing Assistant (CNA), was in Resident #93's bathroom assisting the resident with toileting. Staff C had gloves, but no gown. During an interview on 4/8/2025 at 4:51 PM, Staff C, CNA, stated, I was helping [Resident #93's name] transfer to the toilet and helped her lift her brief. Review of Resident #93's physician order dated 4/4/2025 read, Enhanced Barrier Precautions-Wounds every shift. 3) During an observation on 4/9/2025 at 11:47 AM, Staff C, CNA, was assisting Resident #6 to get dressed while in her bed. Staff C had gloves on, but did not have a gown. Review of Resident #6's physician order dated 12/7/2024 read, Enhanced Barrier Precaution in place (i.e. precautions for door handle. Stop sign, PPE [personal protective equipment] every shift. Open wound every shift for wound. During an interview on 4/9/2025 at 1:57 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, Staff are expected to wear gloves and gown when a resident is under enhanced barrier precautions and they are going to provide direct care to them. [Resident #6 and Resident #93's names] are both under enhanced barrier precautions. During an interview on 4/9/2025 at 2:00 PM, Staff C, CNA, stated, I was not aware that [Resident #93 and Resident #6's names] had wounds and were on enhanced barrier precautions. Residents that have enhance barrier precautions, you should wear a gown and gloves when providing care. I was assisting [Resident #6's name] to get dressed. I did not gown because I did not know they [Resident #6 and Resident #93] were on enhanced barrier precautions. During an interview on 4/9/2025 at 4:08 PM, the DON stated, Staff should wear a gown and gloves when going into an enhance barrier room to provide direct care to the resident. 4) During an observation 4/10/2025 at 11:04 AM, Staff L, Registered Nurse (RN), entered Resident #2's room to provide wound care. Staff L donned gloves and a gown. Staff L adjusted Resident #2's foley tubing. Staff L removed gloves, and without performing hand hygiene, donned a new pair of gloves and removed the dressing on Resident #2's left foot. Staff L removed her gloves, and without performing hand hygiene, donned a new pair of gloves. Staff L cleaned the right side of the left foot that had a wound. Without changing gloves or performing hand hygiene, Staff L cleaned another wound on the left side of the foot. Staff L removed her gloves, and without performing hand hygiene, donned new pair of gloves and applied treatment and new dressing to Resident #2's left foot. Staff L removed her gloves and gown and performed hand hygiene. During an interview on 4/10/2025 at 11:14 AM, Staff L, RN, stated, I should have done hand hygiene in between changing gloves. During an interview on 4/10/2025 at 11:31 AM, the DON stated, Staff should perform hand hygiene when removing gloves. It is two different wounds. I would expect staff to change gloves and perform hand hygiene in between wounds. Changing gloves does not substitute hand hygiene. 5) Review of Resident #114's skin evaluation dated 4/1/2025 read, A. Observations . Site: 6. Right shoulder (front) suture noted and 2 shunts for dialysis present. During an interview on 4/10/2025 at 11:29 AM, the DON confirmed that Resident #114 was not on enhanced barrier precautions and stated, [Resident #114's name] should have orders in place for enhanced barrier precautions. Review of the facility policy and procedure titled Enhanced Barrier Precautions with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organism . Procedure . 2. Initiation of Enhanced Barrier Precautions . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) regardless of MDRO [multidrug resistant organisms] colonization status . 4. For residents for whom EBP [Enhanced Barrier Precautions] are indicated, EBP is employed when performing the following High-Contact care activities- a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator, h. wound care: any skin opening requiring a dressing. 50123 6) During an observation on 4/7/2025 at 9:57 AM, there was a nasal cannula tubing connected to an oxygen concentrator, which was placed unbagged in the drawer of the bedside table in Resident #87's room (Photographic evidence obtained). During an observation on 4/7/2025 at 10:16 AM, there was a nasal cannula tubing connected to an oxygen concentrator laying directly on the floor unbagged in Resident #51's room (Photographic evidence obtained). During an interview on 4/8/2025 at 1:30 PM, Staff E, LPN, Unit Manager, stated, Oxygen tubing should be bagged when it is not in use. During an interview on 4/8/2025 at 12:30 PM, the DON, stated, All oxygen tubing should be bagged when not in use. Review of the facility policy and procedure titled Oxygen Administration with an effective date of 4/1/2022 and last review date of 1/21/2025, read, General Guidelines . 5. All disposable equipment labeled with the resident's name, the date it was opened or provided, and should be changed a minimum of every 7 days. 50695 7) During an observation on 4/9/2025 at 8:57 AM, Staff A, LPN, obtained a blood pressure reading and a pulse oximetry reading from Resident #321. Staff A did not clean the blood pressure cuff or the pulse oximeter. Staff A used the same equipment on Resident #324 to obtain a pulse oximetry reading and to attempt to obtain blood pressure reading. Staff A used a second blood pressure cuff to obtain a blood pressure reading from Resident #321 at 9:25 AM. Staff A did not clean the blood pressure cuff after using it and before returning it to a drawer. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated, I should have cleaned the blood pressure cuff and pulse ox [oximeter] between patients. During an observation on 4/9/2025 at 9:49 AM, Staff A, LPN, removed two tablets for Resident #61 from the blister packs directly into his hand and then placed them in the resident's medication cup. While preparing oral medications for administration for Resident #61, three pills dropped onto the top of the medication cart. Staff A placed two pills into the medicine cup for administration to the resident and discarded one pill into the drug disposal system. During an interview on 4/9/2025 at 10:05 AM, Staff A, LPN, stated that he was unaware that he needed to avoid touching medications. During an interview on 4/9/2025 at 12:50 PM, the DON stated that the expectation was for nurses to clean equipment between residents and that they should not touch medications with their hands. During an observation on 4/10/2025 at 8:45 AM, Staff A, LPN, administered three medications to Resident #116 via percutaneous endoscopic gastrostomy (PEG) tube after donning gloves. Staff A did not don a gown. Review of Resident #116's physician order 4/4/2025 read, Enhanced Barrier Precautions for g-tube, every shift. During an interview on 4/10/2025 at 8:55 AM, Staff A, LPN, stated that EBP meant he needed a barrier on the surface used during medication preparation and administration. Staff A then stated he should have worn gown while administering medications through a PEG tube. During an interview on 4/10/2025 at 11:30 AM, the DON stated, If residents are admitted with a PEG tube, catheter, intravenous line, or wound, they were placed on EBP. A nurse is expected to wear a gown and gloves while administering medication through a PEG tube. Review of the facility policy and procedure titled Administering Medications with an effective date of 4/1/2022 and the last review date of 1/21/2025, read, Purpose: To ensure that medications are administered in a safe and timely manner, and as prescribed. General Guidelines . 23. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medication as applicable. Review of the facility policy and procedure titled Hand Hygiene with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: To prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Procedure: 1. All staff should perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Reference the table below for conditions and indications where hand hygiene is required. Note this may not be an all-inclusive list. Indication . Between resident contacts . Before applying and after removing personal protective equipment (PPE), including gloves . Before preparing or handling medications . Before and after handling clean or soiled dressings, linens, etc.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways. Findings include: 1) During an observation on 4/7/2025 at 10:11 AM, Resident #95 was lying in bed. There was one bottle of nasal saline spray on top of the nightstand. During an interview on 4/7/2025 at 10:11 AM, Resident #95 stated, I have used the spray for years. I will use the nasal spray at night if I feel clogged. During an interview on 4/7/2025 at 12:48 PM, Staff E, Licensed Practical Nurse (LPN), Unit Manager, stated, [Resident #95's name] should not have medication at bedside. We do not really have any resident that self-administers medication. If they do, we would have to evaluate the resident and care plan them. We would also have to put an order in place. 2) During an observation on 4/7/2025 at 10:56 AM, Resident #45 was lying in bed. There was one bottle of lubricant eye drops on top of the bedside table and one bottle of antifungal powder on top of the wall air conditioning unit. During an interview on 4/7/2025 at 10:56 AM, Resident #45 stated, The eye drops are mine. I use them when I need them. I will have the nurses assist with applying them, and the antifungal powder, the nurses will apply for me. 3) During an observation on 4/7/2025 at 12:45 PM, Resident #64 was lying in bed. There was one tube of Neosporin antibiotic ointment on the side of the resident's bed. During an interview on 4/7/2025 at 12:45 PM, Resident #64 stated, I forgot I had the ointment. My family brought it for me. During an interview on 4/7/2025 at 12:48 PM, Staff D, LPN, stated, [Resident #64's name] has no orders for Neosporin. I do not know what she uses it for. Normally they bring meds, and we will provide it for them and get an order. During an interview on 4/7/2025 at 2:33 PM, Staff E, LPN, Unit Manager, stated, [Resident #64's name] cannot self-administer medication. I spoke to the family and they do not know how she got the ointment. 4) During an observation on 4/8/2025 at 8:30 AM, Resident #6 was sitting up in bed. There was a medication cup containing one white circular pill. During an interview on 4/8/2025 at 8:30 AM, Resident #6 stated, I do not know what that medication is for. Can you call the nurse so she can tell us what it is? During an interview on 4/8/2025 at 8:32 AM, Staff D, LPN, stated, The medication in the medication cup is Tramadol. I thought she had taken all her medications while I was here earlier. During an interview on 4/9/2025 at 4:04 PM, the Director of Nursing (DON) stated, If a resident has a high BIMS [Brief Interview for Mental Status score] and they are cognitively intact, they would be able to self-administer and we would evaluate. We did not have any resident in the building that would self-administer medication. Medication should not be left unattended in a resident's room. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/21/2025 read, General Guidelines . 25. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have decision-making capacity to do so safety. Review of the facility policy and procedure titled Medication Storage with the last review date of 1/21/2025 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL Department of Health Guidelines.

Based on observation, record review, and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 3 of 8 residents reviewed, Residents #2, #18, and #49. Findings include: 1) During an interview on 4/7/2025 at 12:20 PM, Resident #2's Son stated, [Resident #2's name] sometimes has a hard time seeing and will have a hard time doing things herself. She [Resident #2] needs help with feeding and getting dressed. Review of Resident #2's Quarterly MDS assessment dated [DATE] read, Section B- Hearing, Speech and Vision . B1000. Vision. Ability to see in adequate light (with glasses or other visual appliances). 0. Adequate . B1200. Corrective Lenses. Corrective lenses (Contacts, glasses, or magnifying glass) used in completing B1000, Vision. 0. No. Review of Resident #2 Optometry Evaluation dated 11/20/2024 showed the resident used corrective lenses. During an interview on 4/10/2025 at 11:15 AM, Staff L, Registered Nurse (RN) stated, [Resident #2's name] has glaucoma and has trouble with her vision. The staff assist her with feeding, and we try to encourage her [Resident #2] to go to the dining room, but she likes to stay in her room. During an interview on 4/10/2025 at 11:50 AM, Staff K, MDS Coordinator, stated, [Resident #2's name] MDS Section B was inaccurate and needs to be corrected. Her vision is not adequate without corrective lens. Review of the facility policy and procedure titled Nursing- Minimum Data Set (MDS) with the last review date of 1/21/2025 read, Purpose: To ensure that the center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weakness and preferences using the federal and/or state required RAI [Resident Assessment Instrument]. 50695 2) During an interview on 4/7/2025 at 10:19 AM, Resident #49 stated that his gastrostomy tube was being used for his medications. Review of Resident #49's MDS assessment dated [DATE] read, Section K- Swallowing/Nutritional Status. K0100. Swallowing Disorder . Z. None of the above . K0520. Nutritional Approaches . B. Feeding tube (e.g., nasogastric or abdominal (PEG)) [No box checked to indicate the resident having feeding tube while a resident]. During an interview on 4/10/2025 at 11:50 AM, the MDS Coordinator stated that the documentation of Resident #49 not having a PEG, or any type of feeding tube was incorrect. 50123 3) During an observation on 4/7/2025 at 9:30 AM, Resident #18 was edentulous. During an interview on 4/7/2025 at 9:30 AM, Resident #18 stated, I'm on mechanical soft because my dentures broke a while back and they still have not gotten me any. I hate having no teeth and not being able to eat. I've seen dental and they told me it'd be an issue because of my overbite. I don't want any surgery or anything. I just want my teeth back. Review of Resident #18's MDS assessment dated [DATE] showed no broken dentures or resident being edentulous under section L- Oral/ Dental Status. During an interview on 4/10/2025 at 12:00 PM, Staff K, MDS Coordinator, stated, It was marked incorrectly on her annual assessment.

Based on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents reviewed for unnecessary medications, Resident #61. Findings include: Review of Resident #61's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including bipolar disorder (onset date of 3/10/2025), major depressive disorder, and anxiety disorder. Review of Resident #61's Level I PASRR dated 3/5/2025 showed anxiety disorder and depressive disorder listed under mental illness. No bipolar disease was listed. Review of Resident #61's hospital discharge summary dated 3/7/2025 read, Hospital course to date . complex past medical history including . bipolar disease. Review of Resident #61's MDS assessment dated [DATE] showed anxiety disorder, depression and bipolar disorder under Section I- Active Diagnoses. During an interview on 4/10/2025 at 8:15 AM, the Administrator stated, When a resident is admitted from the hospital, it is our responsibility to review the PASRR for accuracy and get it corrected if necessary. We did not follow our process. Review of Resident #61's visit note for psychiatric services dated 3/24/2025 read, HPI [History of Present Illness] General . admitted to the facility on 3.9.25 . She has a hx [history of] DMI [diabetic muscle infarction], COPD [chronic obstructive pulmonary disease], morbid obesity, HTN [hypertension], bipolar, MDD [major depressive disorder], anxiety, RLS [restless leg syndrome]. Review of the facility policy and procedure titled Social Services- PASRR with an effective date of 4/1/2022 and the last review date of 1/21/2025 read, Purpose: The facility shall ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to meet their needs . Procedure: I. Preadmission Screening: 1. The External Liaison or Internal Admission Staff/Designee will obtain a completed preadmission screen (PASRR Level I) on all individuals being admitted to the Skilled Nursing Facility (SNF) prior to admission.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 9 residents reviewed, Residents #3 and #114. Findings include: 1) Review of Resident #3's transfer/discharge report showed the resident was admitted on [DATE] with diagnoses including generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of Resident #3's physician order dated 3/5/2025 read, Behaviors- Monitor for the following: Sad affect, continuous crying, seems withdrawn, mood changes, Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift. Review of Resident #3's visit note for psychiatric services dated 3/6/2025 read, DX [Diagnosis] . 1: Generalized anxiety disorder: Patient is stable. Staff to monitor, document, and report worsening symptoms of anxiety symptoms: excessive worry, not able to control worry, restlessness/agitation, being easily fatigued, poor concentration, irritability, muscle tension, sleep disturbance, panic attacks . 4: Post-traumatic stress disorder: Patient is stable. Continue to monitor for changes. Review of Resident #3's care plan did not show a focus for generalized anxiety or post-traumatic stress disorder. During an interview on 4/10/2025 at 11:46 AM, Staff K, Minimum Data Set (MDS) Coordinator, stated, [Resident #3's name] has a diagnosis of post-traumatic stress disorder. The PTSD or anxiety were not included in her care plan and needs to be added. 2) Review of Resident #114's physician order dated 4/1/2025 read, Dialysis on T-Th-Sa@ [Tuesdays-Thursdays-Saturdays at] 10:15 AM at [local dialysis center's name] every day shift every Tue, Thu, Sat, for dialysis. Review of Resident #114's skin evaluation dated 4/1/2025 read, A. Observations . Site: 6) Right Shoulder (front), Description: Suture noted and 2 shunts for dialysis present. Review of Resident #114's care plan showed no focus for enhanced barrier precautions. During an interview on 4/10/2025 at 9:43 AM, Staff E, Licensed Practical Nurse (LPN) Unit Manager, stated, [Resident #114's name] is a dialysis patient and has a catheter on his right chest. He [Resident #114] would need to have enhanced barrier precaution orders and also be care planned. During an interview on 4/10/2025 at 11:29 AM, the Director of Nursing stated, [Resident #114's name] should be care planned for enhance barrier precautions due to the catheter he has in place for dialysis. During an interview on 4/10/2025 at 11:51 PM, Staff K, MDS Coordinator, stated, Currently there are no orders for enhance barrier precautions for [Resident #114's name]. We also go by hospital records. We would expect to see a focus for enhanced barrier precautions as part of his [Resident #114] care plan. Enhance barrier precautions will need to be added to his care plan. Review of the facility policy and procedure titled Nursing- Care Plans- Comprehensive- Person Centered with the last review date of 1/21/2025 read, Purpose: To ensure the development and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Policy . 9. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on record review and interview, the facility failed to ensure the medication regimen recommendations agreed by the physician were followed for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 2/25/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if appropriate. The physician's response was documented as, Agree; will do. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Per clinical record resident with recent falls. A daily intake of 800-1,000 IU of Vitamin D is currently recommended in the elderly to maintain bone health and reduce the risk of falls and fractures. Please evaluate. Consider adding Vitamin D3, 1000 IU once daily, if appropriate. The physician's response was documented as, Agree; will do. Review of Resident #8's current physician orders showed no order for Vitamin D3. During an interview on 4/9/2025 at 2:51 PM, the Director of Nursing (DON) stated, The monthly recommendations [from the Consultant Pharmacist] are divided between the unit managers and the ADON [Assistant Director of Nursing]. The expectation is whoever gets an order from a provider should address it in the computer [electronic medical record]. During an interview on 4/10/2025 at 3:49 PM, the Nurse Practitioner 1 stated, The expectation for the medication regimen reviews is that if we fill out those papers, they [the facility staff] are supposed to update the orders. We cannot write the information in 3 or 4 different places. That is why we write the responses on the pharmacy reviews. Review of the facility policy and procedure titled Pharmacy Services - Drug Regimen Review with an effective date of 4/1/2022, and the last review date of 1/21/2025, read, Purpose: The facility shall maintain the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing. Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon.

Based on record review and interview, the facility failed to ensure residents' medication regimen was free from unnecessary drugs, for 1 of 5 residents reviewed for unnecessary medications, Resident #8. Findings include: Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 1/9/2025 that read, Currently receiving Guaifenesin LA [long acting] tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Agree; will do. DC [Discontinue]. Review of Resident #8's medication regimen review showed the consultant pharmacist's recommendation dated 3/26/2025 that read, Currently receiving Guaifenesin LA tabs (Mucinex) without a stop date. Please evaluate current need. Consider add stop date, if appropriate. The physician's response was documented as, Disagree; State Reason: PRN [as needed]. The physician signed the recommendation on 4/1/2025. Review of Resident #8's physician order dated 1/7/2025 read, Guaifenesin ER [extended release] Oral Tablet Extended Release 12 Hour 600 MG [milligram] (Guaifenesin), Give 600 mg by mouth two times a day for congestion. Order Status: Active. Review of Resident #8's Medication Administration Records (MARs) for administration of Guaifenesin showed the resident received the medication from 1/8/2025 through 1/31/2025, from 2/6/2025 through 2/28/2025, from 3/1/2025 through 3/31/2025, from 4/1/2025 through 4/9/2025 at 9:00 AM and 9:00 PM. During an interview on 4/9/2025 at 2:51 PM, the Director of Nursing (DON) stated, The monthly recommendations [from the Consultant Pharmacist] are divided between the unit managers and the ADON [Assistant Director of Nursing]. The expectation is whoever gets an order from a provider should address it in the computer [electronic medical record]. During an interview on 4/10/2025 at 3:49 PM, the Nurse Practitioner 1 stated, The expectation for the medication regimen reviews is that if we fill out those papers, they [the facility staff] are supposed to update the orders. We cannot write the information in 3 or 4 different places. That is why we write the responses on the pharmacy reviews. Review of the facility policy and procedure titled Pharmacy Services - Drug Regimen Review with an effective date of 4/1/2022, and the last review date of 1/21/2025, read, Purpose: The facility shall maintain the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing. Procedure: 1. The drug regimen of each resident should be reviewed at least monthly by a licensed pharmacist and the pharmacist should report any irregularities to the attending physician, the facility's medical director and the director of nursing and these reports should be acted upon. 2. Irregularities include, but are not limited to, any drug that meets the following criteria . b. Excessive duration, or c. Without adequate monitoring; or d. Without adequate indications for its use . 5. The attending physician shall document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it.