Every finding on record at Lakes of Clermont Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to obtain physician orders to provide wound care for 1 of 2 residents, Residents #45, reviewed for skin conditions.Findings include:During an observation on 2/23/2026 at 11:20 AM, Resident #45 was sitting in his wheelchair in his room. There was a dressing on Resident #45's right forearm with dark color dried substance matter on the dressing. The dressing did not have a date or initials (photographic evidence obtained).During an interview on 2/23/2026 at 11:20 AM, Resident #45 stated, This is a skin tear on my arm, but I do not recall how I got it.During an observation on 2/24/2026 at approximately 8:05 AM, Resident #45 was sitting up in his bed. There was a dressing on his right forearm with dark substance matter. The dressing was not dated or initialed. Review of Resident #45's physician orders revealed no wound care or dressing change orders in place.Review of Resident #45's Treatment Administration Record for February 2026 revealed no wound care or dressing change.During an observation on 2/24/2026 at 1:21 PM with Staff D, Licensed Practical Nurse (LPN), there was a dressing on Resident #45's right arm with dark substance matter on the dressing, and the dressing was not dated. During an interview on 2/24/2026 at 1:21 PM, Staff D, LPN, stated, I do not know why [Resident #45's name] has a dressing on his right arm. I will have to check with the wound care nurse. He [Resident #45] does not have any dressing orders in place. All wounds or skin tears must have an order. The dressing must be dated and initialed.During an interview on 2/24/2026 at 1:28 PM, the Wound Care Nurse stated, [Resident #45's name] has a skin tear and will need dressing care orders to be put in place.During an interview on 2/24/2026 at 9:49 AM, the Director of Nursing stated, Nurses should follow wound care protocol.Review of the facility policy and procedures titled Wound Care with the last review date of 1/30/2026 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care procedures and treatment should be performed according to physician orders.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory in accordance with professional standard of practice for 1 of 2 residents, Resident #96, reviewed for respiratory services.Findings include:During an observation on 2/23/2026 at 9:53 AM, Resident #96 was lying in bed, receiving oxygen via nasal cannula at 3 liters per minute. The resident was not in acute respiratory distress at the time of observation.During an interview on 2/23/2026 at 9:54 AM, Resident #96 stated, I don't need any oxygen. My oxygen is usually 97 and 98%. The resident denied shortness of breath at the time of interview.Review of Resident #96's physician orders revealed no physician order for oxygen therapy.During an observation on 2/24/2026 at 8:41 AM, Resident #96 was lying in bed, receiving oxygen via nasal cannula at 3 liters per minute. The resident was not in acute respiratory distress at the time of observation.During an interview on 2/24/2026 at 9:04 AM, Staff D, Licensed Practical Nurse (LPN), stated, The oxygen was set at 3 liter per minute. Staff D reviewed the electronic medical records and stated, I don't see a doctor's order.During an interview on 2/24/2026 at 9:05 AM, the Assistant Director of Nursing (ADON) stated, I don't see an order for oxygen. The nurse forgot to put the order in when the resident oxygen was at 89. Nursing staff is to verify the O2 [oxygen] orders when they are administering the oxygen.Review of the facility policy and procedures titled Respiratory Care with the last review date of 1/30/2026 read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedures: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/PleurX care, BiPAP [Bilevel Positive Airway Pressure], CPAP [Continuous Positive Airway Pressure] or medication administration.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 2 of 4 units. Findings include: 1) During an observation on 2/23/2026 at 10:47 AM, Resident #97 was lying in bed with eyes closed. On top of the cabinet table across from the resident's bed, there was one blue bottle of Wound Cleansing Solution (Photographic evidence obtained). During an observation on 2/23/2026 at 2:30 PM, Resident #97 was lying in bed. On top of the cabinet table across from the resident's bed, there was one bottle of Wound Cleansing Solution. During an interview on 2/23/2026 at 3:42 PM, Staff C, Licensed Practical Nurse (LPN), stated, The wound cleanser should not have been left in [Resident #97's name] room. It [wound cleanser] should be stored in the treatment cart. 2) During an observation on 2/23/2026 at 11:09 AM, Resident #108 was sitting in a wheelchair in her room. There was one container of zinc oxide diaper rash cream, and one bottle of Ammonium Lactate 12% (Photographic evidence obtained). During an interview on 2/23/2026 at 11:09 AM, Resident #108 stated, Those are creams that I use. During an interview on 2/23/2026 at 3:00 PM, Staff D, LPN, confirmed there were one container of zinc oxide cream and one bottle of Ammonium Lactate 12% unsecured in the resident room, and stated, [Resident #108's name] daughter will bring in medications even after we have told her they are not allowed. Residents are not allowed to keep medications at bedside. They must be stored in the medication cart. During an interview on 2/23/2026 at 3:06 PM, Resident #108's Representative stated, I was not aware that she [Resident #108] was not able to have [brand name of the zinc oxide cream] at bedside. The staff have never told me I cannot have it at bedside. I used it to apply it under her [Resident #108] creases. During an interview on 2/26/2026 at 12:51 PM, the Director of Nursing stated, Medications are not to be left unattended in the residents room. For a resident to self-administer, there should be orders in place, an assessment, and a lock box provided. We do have family that will bring medications without us knowing. 3) During an observation on 2/23/2026 at 9:45 AM, there was one tube of Polysporin and one tube of Bacitracin on Resident #67's bedside table (Photographic evidence obtained). During an interview on 2/23/2026 at 2:28 PM, Staff F, LPN, confirmed that the medications should not be at bedside. 4) During an observation on 2/23/2026 at 10:30 AM, there was one tube of Athlete's foot cream (Terbinafine Hydrochloride Cream 1%) on Resident #32's bedside table (Photographic evidence obtained). During an interview on 2/23/2026 at 2:36 PM, Staff F, LPN, stated that the medication should not be at the bedside. Review of the facility policy and procedure titled Medication/Biological Storage with the last review date of 1/30/2026 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while distributing water, providing wound care, and administering medications, and failed to ensure staff used proper Personal Protective Equipment (PPE) while providing care and services for 1 of 3 residents, Resident #97, reviewed for transmission-based precautions to prevent the possible spread of infection and communicable diseases.Findings include:1) During an observation on 2/23/2026 beginning at 2:30 PM Staff A, Certified Nursing Assistant (CNA), was carrying three foam cups that had lids on them and straws inserted through the lids. The cups were labeled 2/23/2026, 7P - 7A (indicates the 7:00 PM shift that ended at 7:00 AM in the morning). Staff A placed the used cups on the second shelf of a three-tier pushcart. Staff A did not perform hand hygiene and touched multiple cups located on the top shelf of the cart in preparation for delivery to the residents. The cups were labeled 2/23/2026, 2 PM. Staff A did not perform hand hygiene and retrieved two of the new cups filled with water and began walking down the hall to deliver the cups to residents' rooms. Staff A exited the rooms, was not observed to perform hand hygiene, and walked off the unit. At 2:47 PM, Staff A returned to the unit and began pushing the three-tier cart down the hallway. Without performing hand hygiene, Staff A removed two of the new cups filled with water from the top shelf of the cart and entered Resident #101's room. Staff A delivered the water cup, removed a used water cup from Resident #101's room, placing it to the second shelf of the pushcart. Staff A did not perform hand hygiene and delivered a new water cup to Resident #14's room.During an interview on 2/23/2026 at 2:49 PM, Staff A, CNA, stated, The three cups I placed on the second shelf were cups that I brought out from residents' rooms. I should have performed hand hygiene in-between delivering of the cups and after placing the old cups on the cart.During an interview on 2/26/2026 at 12:47 PM, the Assistant Director of Nursing/Infection Preventionist stated, Staff should throw away the old cups of water and not place them on the cart that contains the new cups of water that are being passed out. The staff should perform hand hygiene in-between each delivery to each resident. I tell staff that residents touch the cups. The residents are touching their environment and different areas of their body; then the staff touch the cups with their hands. If staff do not perform hand hygiene, they will have whatever the resident had on their hands and will spread it.During an interview on 2/26/2026 at 12:51 PM, the Director of Nursing stated, Staff should throw away the old water cups and wash their hands in-between. The staff should follow the hand-washing protocol.2) During an observation on 2/23/2026 at 2:34 PM, there was a contact precautions signage posted outside Resident #97's room, with PPE supplies available in a plastic bin. Resident #97's call light was activated. Staff B, CNA, entered Resident #97's room, carrying a foam cup without donning gloves and a gown. Staff B exited Resident #97's room and the call light remained activated. Staff B re-entered Resident #97's room without donning gloves or a gown and turned off the call light.During an observation on 2/23/2026 at 3:38 PM, Staff C, Licensed Practical Nurse (LPN), entered Resident #97's room without donning gloves or gown and removed wound cleanser solution from Resident #97's room.Review of Resident #97's physician order dated 2/18/2025 read, Contact Isolation- MRSA [Methicillin-resistant Staphylococcus aureus] in the wound. All care provided in room every shift.During an interview on 2/25/2026 at 2:37 PM, Staff B, CNA, stated, I should have put on a gown before entering the [Resident #97's name] room. I was in a lot of pain and was not feeling well.Review of the facility policy and procedure titled Transmission Based Precautions with the last review date of 1/30/2026 read, Guidelines for Contact Precautions: Gloves: 2. [NAME] gloves upon entry into the room or cubicle. Gowns: 1. [NAME] gown upon entry into the room or cubicle. 3) During an observation on 2/25/2026 at 6:13 AM, Staff E, Registered Nurse (RN), did not locate NovoLog in the medication cart for Resident #48's insulin administration. Staff E closed the medication cart, walked to the medication room, retrieved a NovoLog pen from the medication overstock refrigerator, and returned to the medication cart. Staff E did not perform hand hygiene, donned gloves, removed the gloves, and disposed of the gloves in the trash bin. One of the gloves fell out of the trash bin. Staff E picked the glove up off of the floor and disposed of the glove into the trash bin. Staff E did not perform hand hygiene and labeled the NovoLog pen with Resident #48's name. Staff E did not perform hand hygiene, donned gloves, entered Resident #48's room, did not remove the gloves and did not perform hand hygiene, and conducted an accu-chek (a test to determine blood sugar level) on Resident #48. Staff E returned to the medication cart, removed the gloves, disposed of the gloves in the trash bin, did not perform hand hygiene, and documented the blood sugar level in the electronic system. Staff E walked over to Resident #48's room, took the resident's vital signs, walked over to a different medication cart, did not perform hand hygiene, and poured Resident #48's medications into a medication cup. Staff E did not perform hand hygiene, administered Resident #48's medications, returned to the medication cart, and performed hand hygiene.During an interview on 2/25/2026 at 6:50 AM, Staff E, RN, stated, I thought I had done hand hygiene in-between. In my mind maybe I did. I should have done hand hygiene upon returning from the medication room, when I picked up the glove from the floor and every time before putting on a new pair of gloves.4) During an observation on 2/25/2026 at 10:15 AM, the Wound Care Nurse and Staff G, CNA, started providing wound care to Resident #88. Staff G lifted the resident's right leg while the Wound Care Nurse placed a barrier under the resident's leg. The Wound Care Nurse lifted Resident #88's left leg to position the barrier. The Wound Care Nurse did not remove the gloves, did not perform hand hygiene and began cleaning the wound on Resident #88's right leg. The Wound Care Nurse then removed the gloves, performed hand hygiene, donned a new pair of gloves, and applied the treatment and wound dressing to the wound on the resident's right leg. The Wound Care Nurse removed the gloves, performed hand hygiene, and applied skin preparation to Resident #88's left leg. There was a small amount of drainage from the resident's left heel. The Wound Care Nurse exited the room, returned to the treatment cart to obtain additional supplies. Staff G lowered the resident's left leg back onto the barrier, which contained light red drainage. The Wound Care Nurse returned, performed hand hygiene, donned gloves, cleansed the wound on the resident's left foot, did not remove the gloves or perform hand hygiene, and applied the treatment and a wound dressing to the left foot. The Wound Care Nurse then removed the gloves, performed hand hygiene, donned a new pair of gloves, and cleansed Resident #88's sacral wound. The Wound Care Nurse removed the gloves, did not perform hand hygiene, donned a new pair of gloves, applied the treatment and wound dressing to the sacral wound. The Wound Care Nurse then removed the gloves and performed hand hygiene.During an interview on 2/25/2026 at 10:56 AM, the Wound Care Nurse stated, I should have removed my gloves and performed hand hygiene after touching his [Resident #88] left leg, before cleaning the wound on his right leg. Once the foot was placed on the barrier, I should have cleaned the area and then applied the treatment and dressing. I should perform hand hygiene when removing the gloves and donning a new pair and in between the steps of wound care.During an interview on 2/26/2026 at 8:27 AM, the Assistant Director of Nursing/Infection Preventionist stated, The staff should don PPE before entering a resident's room who is on contact precautions. Staff should wash their hands first when they come back to the medication cart after exiting the medication room. They should clean their hands before handling medication. They should perform hand hygiene before and after removing gloves. During wound care staff should wash their hands after touching any new area. Every time you change your gloves you have to clean your hands.During an interview on 2/26/2026 at 9:47 AM, the Director of Nursing stated, The nurses should follow the contact precaution protocols. We have signs posted on the room doors and the staff are supposed to don the personal protective equipment instructed to use. The staff should follow wound care protocols. The nurses should perform hand hygiene when returning to the medication cart, after picking up items from the floor, in-between residents and when changing gloves.Review of the facility policy and procedures titled Hand Hygiene with the last review date of 1/30/2026 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Use an alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; g. Before handling clean or souled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; o. Before and after eating or handling food; 7. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on record review and interview, the facility failed to ensure the resident's family/responsible party was notified of falls, physician orders, and hospital transfer for 1 of 3 residents, Resident #1, reviewed for falls. Findings include: Review of Resident #1's clinical record documented the resident was admitted on [DATE] with diagnosis including but not limited to unspecified fracture of the upper end of the right tibia, encounter for other orthopedic aftercare, cellulitis (infection of the skin) of the right lower limb, repeat falls, abnormalities of gait and mobility, muscle weakness, muscle wasting and atrophy (wasting of muscle). Review of Resident #1's nurses note dated 5/22/2025 at 16:56 (4:56 PM) read Patient was seated on the floor on her buttocks in front of her wheelchair with legs extended out in front of her. Patient denies hitting her head. Able to move all extremities within normal limits. Review of Resident #1's clinical record found it did not contain documentation of Resident #1's family/responsible party being notified at time of fall. Review of Resident #1 SBAR (Situation Background Assessment Response) Communication Form dated 5/22/2025 at 12:00 AM read . Resident was observed sitting on the floor in front of her WC [Wheelchair] . son visiting 5/22/2025 12:00 AM. Review of Resident #1's progress note dated 5/23/2025 at 01:00 AM read einteract SBAR for providers, Situation: The change in condition (CIC)/s reported on this CIC evaluation are/were: fall .new test ordered x-ray. Review of Resident #1's clinical record found it did not contain documentation of Resident #1's family/responsible party being notified of the fall and the physician's order for an x-ray. Review of Resident #1's health status note dated 5/23/2025 at 14:41 [2:41 PM] read ARNP [Advance Registered Nurse Practitioner] here to see resident new orders for Portable 3 view x-ray right knee, Dx [diagnosis]: pain, portable d/t [due to] weakness/fall risk. Review of Resident #1's einteract SBAR Summary for providers note dated 5/23/2025 at 20:40 PM [8:40 PM] read Transfer to hospital STAT [immediately]. Review of Resident #1's clinical record found it did not contain documentation of Resident #1's family/responsible party being notified of Resident #1's transfer to the hospital. During an interview on 6/2/2025 at 07:10 PM the Director of Nursing (DON) stated, [Resident #1's name] had two falls and I believe that both falls were on 5/22/2025. During the first fall the son was not notified. When he came into the facility he was informed of the fall and that she had an additional fall at the same time. With the last fall she had increased pain in her leg, so an X-ray was completed. It was the same fracture that she had when she came into the facility, but the son wanted her to be transferred to the ER [emergency room]. We transferred her. If the residents are responsible for themselves and are alert and oriented x 4 [alert and oriented to person, place, time, and event], the facility does not have to contact the family if a fall occurs. During an interview on 6/2/2025 at 08:45 PM Staff A, License practical Nurse (LPN) stated, We do contact the physician and family when patients fall. During an interview on 6/2/2025 at 08:52 PM Staff B, LPN Supervisor stated, I remember [Resident #1's name] had a fall and then she fell again. At neither time her son was not here, but I met the son I know he knows. To be quite honest I am not sure if he was notified of the fall or not that is our protocol to notify family. I don't want to say it was or it was not because I just responded to the call and will tell the nurse what to do next. It is our protocol to call the family; we even call if the resident is alert and oriented. Family should be notified when a fall occurs. During an interview on 6/2/2025 at 9:14 PM the Administrator stated, The family should be notified anytime a patient has a fall. During a telephone interview on 6/3/2025 at 07:55 AM Staff E, LPN stated, I remember [Resident #1's name]. She was found sitting on the floor; it was about one of two o'clock in the morning. When I came back to work the next day the doctor sent her to the hospital because of her x-ray results. The doctor wanted her to be sent out to the ER because of her x-rays. I did not call the son during the middle of the night to tell him about the fall; I didn't ask her [Resident #1] if she wanted me to call her son, but I did call the doctor and reported the fall and an x-ray was ordered. I am supposed to call the family, the doctor and the ADON [Assistant Director of Nursing] and report the fall. Review of the policy and procedure titled, Change in Condition issued 4/1/2022 read, It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician orders .11. Notify the family or responsible party/resident representative regarding the resident condition change and need to send to hospital or notify emergency services for transport.

Based on observation, record review, and interview, the facility failed to ensure residents received care and services in accordance with professional standards of practice for application of Thrombo-Embolic Deterrent (TED) stockings for 2 of 3 resident reviewed, Residents #174 and #62 (Photographic evidence obtained), and failed to ensure residents received medications as ordered by physician for 3 of 8 residents reviewed for unnecessary medications, Residents#175, #49 and #323. Findings include: 1) Review of Resident #174's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of the right lower limb, atrial fibrillation, thoracic aortic ectasia, and essential (primary) hypertension (high blood pressure). Review of Resident #174's physician order dated 9/8/2024 read, Compression hose to bilat [bilateral] lower extremities in the morning for orthostatic hypotension [low blood pressure] apply in AM [morning] and remove at HS [bedtime] and remove per schedule. During an observation on 9/16/2024 at 10:40 AM, Resident #174 was sitting in his wheelchair, with both legs swollen and no TED stockings applied. During an observation on 9/17/2024 at 12:15 PM, Resident #174 was sitting up in his wheelchair at bedside, with no TED hose applied. During an interview on 9/17/2024 at 12:15 PM, Resident #174's Wife stated, He has not had any special stockings since he has been here at the facility. No one has discussed stockings. During and observation on 9/17/2024 at 1:11 PM, Resident #174 was sitting in his wheelchair, with no TED stockings applied. During an interview on 9/17/2024 at 1:11 PM, Staff A, Certified Nursing Assistant (CNA), confirmed Resident #174 had no TED stockings and stated, No one told me to put TED hose on him. I've never placed TED hose on him. 2) Review of Resident #62's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, essential (primary) hypertension, and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #62's physician order dated 9/8/2024 read, TED hose on in AM and off at HS every shift TED hose on and off at HS. During an observation on 9/16/2024 at 10:40 AM, Resident #62 was lying in bed, with no TED hose on lower leg. Both legs of the resident were red and discolored with scabs. During an observation on 9/17/2024 at 10:00 AM, Resident #62 was lying in the bed, with no TED hose on bilateral lower extremities. During an interview on 9/17/2024 at 1:35 PM, Staff B, Licensed Practical Nurse (LPN), confirmed that Resident #174 and Resident #62 did not have TED stockings/hose on. 3) Review of Resident #175's admission record showed the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia. Review of Resident #175's physician order dated 9/9/2024 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit /ml [milliliters] (Insulin Glargine) Inject 25 unit subcutaneously one time a day for DM [Diabetes Mellitus]. Review of Resident#175's Medication Administration Record (MAR) for September 2024 for administration of Lantus Solostar subcutaneous solution showed the staff documented 4 (4=Held per parameters) for the blood sugar level of 92 on 9/13/2024 at 10:00 PM, 5 (5=Hold/See Nurse Notes) on 9/14/2024 at 10:00 PM with the blood sugar level documented as X, 4 for the blood sugar level of 120 on 9/15/2024 at 10:00 PM, 4 with the blood sugar level documented as X on 9/16/2024 at 10:00 PM and 9/17/2024 at 10:00 PM. During an interview on 9/17/2024 at 12:20 PM, Staff B, LPN, stated, Insulin was not given [to Resident #175] because the blood sugar was out of parameters. During an interview on 9/18/2024 at 1:30 PM, with ARNP #1 stated, I was not informed that the staff was holding her [Resident #175's] Lantus Insulin because her blood sugar was low. I should have been informed, so that I was aware and could adjust her orders as needed. During an interview on 9/18/2024 at 10:05 AM, the Director of Nursing stated, The TED hose were not applied for [Resident #174's name] and [Resident #62's name] as ordered. I expect the physician orders to be followed as ordered. Daily dosage of Lantus Solostar Insulin is to be administered and if not given, the physician has to be called and informed. 40559 4) Review of Resident #49's admission record showed the resident was admitted on [DATE] with diagnoses that included disseminated mycobacterium avium-intracellular complex, diverticulitis of large intestine with perforation and abscess without bleeding, colostomy status, bronchiectasis, unsteadiness on feet, and muscle weakness (generalized). Review of Resident #49's physician order dated 9/2/2024 read, Tramadol HCl Oral Tablet 25 MG [milligram] (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for severe pain (7-10). Review of Resident #49's MAR for September 2024 showed the resident received Tramadol HCl on 9/1/2024 at 9:17 PM for a pain level of 6, 9/4/2024 at 5:33 PM for a pain level of 5, 9/11/2024 at 7:00 AM for a pain level of 4, and 9/13/2024 at 8:59 PM for a pain level of 6. 5) Review of Resident #323's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of right lower limb, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, ischemic cardiomyopathy, chronic systolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of Resident #323's physician order dated 9/14/2024 read, Morphine Sulfate Oral Tablet 15 mg (Morphine Sulfate) Give 1 tablet by mouth every 4 hours as needed for pain for 3 days severe pain (7-10) for up to 3 days . Start Date: 09/14/2024. End Date: 09/17/2024. Review of Resident #323's physician order dated 9/16/2024 read, Morphine Sulfate Oral Tablet 15 mg (Morphine Sulfate) Give 1 tablet by mouth every 4 hours as needed for pain for 3 days severe pain (7-10) . Start Date: 09/16/2024. End Date: 09/19/2024. Review of Resident #323's MAR for September 2024 showed the resident received Morphine Sulfate on 9/15/2024 at 11:09 AM for a pain level of 5, 9/15/2024 at 11:47 PM for a pain level of 4, 9/17/2024 at 11:25 AM for a pain level of 5. During an interview on 9/19/2024 at 9:45 AM, the Director of Nursing confirmed the medications were given out of parameters to Resident #49 and Resident #323 and stated that her expectation was that the nurses follow the parameters contained in the orders. Review of the facility policy and procedure titled Standards and Guidelines: SG Medication Administration last reviewed on 1/24/2024 showed it read, Policy: It will be the standard of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: 1) During an observation on 9/16/2024 at 11:47 AM, there were three containers on Resident #32's dresser. One container contained red fluid and the other two contained transparent liquids. All containers had labels that read, Poison/Do Not Drink. During an interview on 9/16/2024 at 11:58 AM, Staff D, Registered Nurse (RN), stated, Those are for stool sample and should be in the bathroom. They were here since Saturday [9/14/2024]. It is poisonous. When we get a sample, we should have them in the bathroom. The medications and biologicals need to be stored in a secured place. During an interview on 9/18/2024 at 3:14 PM, the Director of Nursing stated, The biologicals should be securely stored when the sample is being collected. 49777 2) During an observation on 9/16/2024 at 9:40 AM, there was one anti-itch spray on the bedside table in Resident #44's room. During an interview on 9/16/2024 at 9:40 AM, Resident #44 stated, The spray is for my itchy back. During an interview on 9/18/2024 at 2:30 PM, the Director of Nursing stated, Residents need an order for self-administration of medication and to have the medication at the bedside and we also have to be sure the resident have the capability of taking the medication safely and according to the physician's order. Review of the facility policy and procedure titled Medication Storage revised on 10/24/2022 and last reviewed on 1/24/2024 showed it read, Standard: It will be the standard of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Guidelines . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to ensure stored food items were labeled and dated in Refrigerator No. 1 in the kitchen and in the nourishment room refrigerator (Photographic evidence obtained). Findings include: 1) During an observation while conducting the initial tour of the kitchen on 9/16/2024 at 9:24 AM, there was one bag containing food with no label or date stored in Refrigerator #1 in the kitchen. During an interview on 9/16/2024 at 9:26 AM, the Certified Dietary Manager (CDM) confirmed that the food item stored in Refrigerator #1 did not have a label or date. During an interview on 9/16/2024 at 9:55 AM, Staff E, Dietary Aide, stated the unlabeled bag contained chicken and mashed potato. 2) During an observation on 9/16/2024 at 9:46 AM, there were two bags containing food items with no label and date stored in the refrigerator of the nourishment room. During an interview on 9/16/2024 at 9:46 AM, the CDM identified the food items as yogurt and chicken and confirmed that they were not labeled and dated. 3) During an observation while conducting the second tour of the kitchen on 9/17/2024 at 2:40 PM, there were two bags of food with no label or date in a pan stored in Refrigerator #5 in the kitchen. During an interview on 9/17/2024 at 2:41 PM, the CDM identified the food items as turkey and ham cuts and confirmed that they were not labeled and dated. Review of the facility policy and procedure titled Food Labeling and Dating revised on 3/2/2021 and last reviewed on 1/24/2024 showed it read, Standard: Foods are labeled and dated for identification purposes and to ensure they are discarded within acceptable time frames according to HACCP [ Hazard Analysis Critical Control Point] guidelines. Guidelines: 1. Food products that are purchased and brought into the Food & Nutrition department inventory are dated upon delivery and storage. A permanent marker is used to indicate date opened and date received.

Based on record review and interview, the facility failed to ensure resident records were complete and accurate for 3 of 8 residents reviewed, Residents #174, #62, and #374. 1) Review of Resident #174's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of the right lower limb, atrial fibrillation, thoracic aortic ectasia, and essential (primary) hypertension (high blood pressure). Review of Resident #174's physician order dated 9/8/2024 read, Compression hose to bilat [bilateral] lower extremities in the morning for orthostatic hypotension [low blood pressure] apply in AM [morning] and remove at HS [bedtime] and remove per schedule. During an observation on 9/16/2024 at 10:40 AM, Resident #174 was sitting in his wheelchair, with no TED stockings applied. During an observation on 9/17/2024 at 12:15 PM, Resident #174 was sitting up in his wheelchair at bedside, with no TED hose applied. During an interview on 9/17/2024 at 1:11 PM, Staff A, Certified Nursing Assistant (CNA), confirmed Resident #174 had no TED stockings and stated, No one told me to put TED hose on him. I've never placed TED hose on him. Review of Resident #174's Treatment Administration Record (TAR) for September 2024 for application of compression hose showed the treatment was administered on 9/8/2024 through 9/17/2024 at 9:00 AM and removed on 9/8/2024 through 9/16/2024 at 8:59 PM. 2) Review of Resident #62's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, essential (primary) hypertension, and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #62's physician order dated 9/8/2024 read, TED hose on in AM and off at HS every shift TED hose on and off at HS. During an observation on 9/16/2024 at 10:40 AM, Resident #62 was lying in bed, with no TED hose on lower leg. During an observation on 9/17/2024 at 10:00 AM, Resident #62 was lying in the bed, with no TED hose on bilateral lower extremities. During an interview on 9/17/2024 at 1:35 PM, Staff B, Licensed Practical Nurse (LPN), confirmed that Resident #174 and Resident #62 did not have TED stockings/hose on. Review of Resident #62's TAR for September 2024 for application of TED hose showed the treatment was administered on 9/3/2024 through 9/16/2024 on day and night shifts. During an interview on 9/18/2024 at 10:05 AM, the Director of Nursing stated, The TED hose were not applied for [Resident #174's name] and [Resident #62's name] as ordered. I expect the physician orders to be followed as ordered. The staff must complete the task first and place the TED hose on the resident and then document on record that the task was completed. They cannot just check the boxes that the task are done and not complete them. 39185 3) Review of Resident #374's admission record showed the resident was admitted on [DATE] with diagnoses that included fracture of third lumbar vertebra, fracture of second lumbar vertebra, syncope and collapse, sequelae of cerebral infarction, polyneuropathies, mild protein-calorie malnutrition, major depressive disorder, hypothyroidism, unsteadiness on feet, and muscle weakness (generalized). Review of Resident #374's physician order dated 9/11/2024 showed it read, Ace-Wrap left ankle every day. Remove at night every shift apply ace wrap in AM, and off at HS. Review of Resident #374's physician order dated 9/5/2024 showed it read, Air mattress to bed monitor for proper placement and functioning every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Apply House barrier cream to buttocks every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Back brace on at all times when out of bed every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Sacrum: apply house barrier cream every shift. Review of Resident #374's TAR for September 2024 showed no entry documented on 9/13/2024 for night shift for administration of Ace-wrap (start date of 9/11/2024 and discontinuation date of 9/16/2024); no entry documented on 9/13/2024 for night shift for monitoring air mattress (start date of 9/5/2024); no entry documented on 9/13/2024 for night shift for applying house barrier cream to buttocks (start date of 9/10/2024); no entry documented on 9/5/2024 and 9/13/2024 for night shift for applying back brace (start date of 9/2/2024); and no entry documented on 9/5/2024 for night shift for applying house barrier cream (start date of 9/5/2024 and discontinuation date of 9/10/2024). During an interview on 9/18/2024 at 4:18 PM, Staff D, Registered Nurse, stated, Nothing was charted. It is red in the PCC [Point Click Care] that means it was not touched. During an interview on 9/19/2024 at 9:19 AM, the Director of Nursing stated that the staff provided the care, but they were interrupted and forgot to complete the MAR. Review of the facility policy and procedure titled Charting and Documentation revised on 3/27/2024 and last reviewed on 1/24/2024 showed it read, Standard: It is the standard of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed . Guidelines: 1.Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment (PPE) while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 9/18/2024 at 9:22 AM, Resident #375's room door had a signage that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. During an observation on 9/18/2024 at 9:28 AM, Staff D, Registered Nurse (RN), entered Resident #375's room wore gloves but did not wear a gown. Staff A applied a dressing on the resident's sacral wound. During an interview on 9/18/2024 at 9:32 AM, Staff D, RN, stated, I didn't use a gown. We need to use gloves only for providing care to the residents on enhanced barrier precautions. Review of Resident #374's physician order dated 9/17/2024 showed it read, Enhanced Barrier Precautions every shift for wound. During an interview on 9/18/2024 at 2:20 PM, the Regional Registered Nurse confirmed that Staff D, RN, did not use the proper personal protective equipment while applying the sacral dressing for a resident on Enhanced Barrier Precautions. Review of the facility policy and procedure titled Transmission Based Precautions revised on 6/10/2024 and last reviewed on 1/24/2024 showed it read, Guidelines . Enhanced Barrier Precautions (EBP): Enhanced Barrier Precautions are a transmission-based approach that falls between Standard and Contact Precautions. These precautions are primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together as part of morning or evening care. EBP, when implemented, are intended to be in place for the duration of a resident's stay in the center or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Examples of high-contact resident care activities requiring gown and glove use include: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing.

Based on observation, interview, and reviews of manufacturer recommendation, and FDA (Food and Drug Administration) safety guide, the facility failed to ensure that residents were free from accidents and hazards by failing to provide adequate supervision for a resident during use of a mechanical lift for obtaining weights. On October 17, 2023, Resident #4 was observed in her room unattended and unsupervised while suspended by a sling of a mechanical lift, hanging in the air over the floor next to her bed. It is unknown how long the resident had been suspended by the sling. The facility's failure to provide supervision and leaving Resident #4 unattended led to the determination of Immediate Jeopardy at a scope and severity of isolated (J). The Nursing Home Administrator was notified of the Immediate Jeopardy on 10/20/2023, at 8:45 AM. The Immediate Jeopardy began on 10/17/2023 and was removed on site on 10/20/2023. A fall from a mechanical lift can cause serious injuries, including bone fractures, internal injuries, spine injuries, traumatic brain injuries and death. Elderly people are very frail, and a fall that would not cause long-term harm to a younger, healthier individual could be fatal for a nursing home resident. Findings include: On 10/17/2023 at approximately 10:45 AM, an observation was made of Resident #4, who was observed to be suspended from a sling of a mechanical lift, which was positioned between the wall and the resident's bed, over the hard floor. At the time of the observation no facility staff were noted in the hallway or in the resident's room and the hallway was free of evidence of a linen cart. The resident had been suspended in the air for an unknown period of time. Approximately 3 minutes into the observation at approximately 10:48 AM, Staff A, Certified Nursing Assistant (CNA) was observed to enter Resident #4's room and proceed to put a flat sheet onto the resident's bed as the resident continued to be suspended in the mechanical lift on the other side of the bed. After the sheet was positioned on the bed, the CNA approached the resident, pushed the lift over the bed, and then lowered the resident onto the bed. On 10/17/2023 at approximately 10:50 AM, an interview was conducted with Staff A, CNA, who stated, It is not appropriate for me to leave the resident in the air. When asked why the staff member did not lower the resident onto the bed or chair prior to exiting the room, Staff A did not respond. When asked the number of staff members required to use a mechanical lift for a resident Staff A stated, I know I need two. During an interview on 10/17/2023 at approximately 10:55 AM Staff B, Licensed Practical Nurse (LPN) stated, I am the nurse for [Resident #4's name]. The CNA should not have left the resident alone in that position, it is not right. During an interview on 10/18/2023 at 8:57 AM, the Director of Nursing (DON) stated, My expectation is for the staff not to put a task [getting linen for the bed] before patient safety. During a follow up interview on 10/18/2023 at 3:00 PM, the DON stated that the modality of the weighing is what keeps the weight consistent. [Staff A's name] has always weighed [Resident 4's name] that way because of her difficulty in walking and standing. We teach the staff that you need two people for the lift. During an interview on 10/18/2023 at 3:10 PM, the Administrator stated, Regardless of what the mechanical lift policy says, we train for two people on the [mechanical] lift. An interview was attempted on 10/19/2023 at 9:10 AM, with Resident #4. Resident #4 was not able to answer simple questions. Was only able to provide her name, was not able to state where she was or the situation. She was able to state she was fine. The resident was confused and laughed repeatedly during the attempted interview. During an interview on 10/19/2023 at 9:24 AM, the Certified Occupational Therapy Assistant (COTA), Interim Rehabilitation Director stated, Every resident is evaluated for Physical Therapy and Occupational Therapy. After the evaluation, therapy will put a blue dot on the resident's door to indicate that they have been assessed for a mechanical lift. The therapy notes would document the resident was maximum assist of two or unable to sit at edge of bed; this indicates that the resident should be transferred with the mechanical lift. Training on mechanical lifts is done by therapy. Every staff member gets trained by the Director of Rehab at orientation covering the transfer technique and process. HR [Human Resources] maintains the checklist for the training. Currently we are training all nursing staff on the proper use of the mechanical lift. Nursing and HR are tracking the staff that are trained on mechanical lifts and will let therapy know when it's complete. The blue dot on the resident's door indicates that the weight has to be done by a mechanical lift as well as the transfers. There should not be a weight taken [by mechanical lift] if there is not a blue dot on the resident's door. Residents will fluctuate in ability to transfer, extreme weakness, for patient and staff safety and a possible need for the mechanical lift. This is communicated to therapy and an evaluation for a mechanical lift will be completed by therapy. [Resident #4's name] has not been assessed for the use of the mechanical lift. During an observation on 10/18/2023 at approximately 9:47 AM, of Resident #4's room door there was no blue dot to indicate the resident had been assessed to be weighed using a mechanical lift and/or for transfers. (Photographic evidence obtained). During an interview on 10/18/2023 at 11:18 AM, via telephone Staff A, CNA stated, I was doing the weights for the resident and noticed the resident was soiled. I cleaned the resident up, put the resident in the sling and raised her up. I left the room to go to the linen cart. The linen cart was outside the door; I was looking for a flat sheet. I weighed the resident using the lift by myself. I didn't put her in the chair or over the bed because the other staff usually come right behind me and get her up to the wheelchair. I did not communicate to anyone I needed help. I do know that to operate the Mechanical lift you are to have two people. During an interview on 10/19/2023 at 10:13 AM, the DON stated [Resident #4's name] pushes on the handles of the scale and we cannot get an accurate weight. That is why the mechanical lift is being used to obtain her weight. She [Resident #4] was not reassessed by therapy before using the mechanical lift for weights. A request was made to view the video footage of the hallway. The DON stated, There was no video of the interior of the building only the exterior of the building. During an interview on 10/19/2023 at 11:55 AM, the Administrator stated, It was not safe to leave a resident alone, unsupervised in a room suspended in a sling of the mechanical lift. The potential would be injury. During an interview on 10/19/2023 at 3:10 PM, the DON stated, The resident [Resident #4] should never be left alone in a sling, the injuries could be numerous; fractures, spinal injury, and even could include death. During an interview on 10/19/2023 at approximately 3:18 PM, with the Administrator and the Regional Director of Clinical Operations a request was made for the policy and procedure for resident supervision and resident safety. At the time of survey exit the facility staff had not provided the requested policy and procedure. Review of the electronic medical record for Resident #4 documented the resident was admitted to facility on 6/15/2023 with a diagnosis of acute cystitis without hematuria, iron deficient anemia, dementia, hypertension, weakness, abnormality of gait, and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] for the Quarterly Brief Interview for Mental Status (BIMS) score was documented as 12, indicating moderate cognitive impairment. Review of the [Psychiatric Association's name] read, Date of Service: 6/29/2023, 81 y/o [year old] not taking any antipsychotics alert responsive with confusion. Dementia: safety concern screening and follow up for patients with dementia staff counseled regarding safety concern: Fall Risk, risk of wandering, and physical aggression. Dated 9/14/2023 Patient is being seen for a follow up visit today. Patient last seen 8/15/2023. Patient is awake and alert. She is oriented to person, confused to place, time and situation. Patient is minimally verbal. Unable to obtain history. Review of the list of residents who have been approved by assessment for the use of a mechanical lift for weighing and/or transfers did not have Resident #4's name documented on the list. Review of the care plan for Resident #4 did not document the use of a mechanical lift for weights and/or transfers. Review of the physician orders for Resident #4 did not document an order for the use of the mechanical life for weights and/or transfers. Review of the policy and procedure titled SG (Standards and Guidelines) Mechanical Lifts read, Standard. It is the standard of this facility to provide a safe environment for our residents and staff. The Nursing and Therapy departments will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/repositioning residents will receive instruction on the safe operation of the mechanical lifts. Guidelines. #5 When using mechanical lift staff will adhere to manufacture guidelines, physicians order and/or the care plan. Review of the Instructions For Use Maxi Move by [Manufacturer Name] under General Information Page 5, read, Note: The need for a second attendant to support the patient must be assessed in each individual case. Review of the FDA Patient Lifts Safety Guide Step #10 reads, Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. The Immediate Jeopardy (IJ) was removed on site on 10/20/2023 after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated 10/20/2023 documented, On 10/17/2023, Resident [#4] was immediately assessed by nurse with no injury or changes from baseline. On 10/17/2023, Staff member [A] identified was immediately removed from the assignment and suspended pending investigation. Staff member [A] was re-educated on not leaving the resident unsupervised and unattended in a mechanical lift and assuring 2 people assist in mechanical lift transfers. On 10/17/2023, a Federal Immediate report was completed for allegation of neglect. DCF (Department of Children and Families) was notified, MD (Medical Doctor) was notified, and family notified of incident. Police were called and no further follow-up required. On 10/17/2023, an audit was completed by Director of Nursing to review the incident log for any incidents or injuries regarding improper use of mechanical lift in the last 90 days. No other incidents were reported. On 10/17/2023, all 18 residents identified as affected by this deficient practice were audited for safety and supervision while using a mechanical lift. No issues were identified. On 10/17/2023, the Director of Nursing and Executive Director were reeducated by the Regional Director of Clinical Operations on the components of this regulation: Free of Accidents and Hazards/Supervision/Devices, providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents Kardex and care plan prior to care and services being rendered, following plan of care, and education on transfer to include mechanical lift - resident safe handling with 2 person assist to ensure supervision. As of 10/20/2023, re-education completed with Licensed nursing staff (RNs [Registered Nurse] and LPNs) and Certified Nursing Assistants by the Director of Nursing Services/designee on the following components of this regulation: Free of Accidents and Hazards/Supervision/Devices, providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents Kardex and care plan prior to care and services being rendered, following plan of care, education on proper transfers to include mechanical lift - resident safe handling with 2 person assist to ensure supervision, competency carried out with return demonstration, and newly hired employees will continue to receive education and competency on above in orientation. Mechanical lift training to include the appropriate number of team members present to utilize the mechanical lift will be included in annual competencies moving forward and will be completed by Director of Nursing/designee. On 10/17/2023, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the above plan [Performance Improvement Plan]. Root Cause Analysis determined: 1. Employee used poor judgement and failed to provide adequate supervision while utilizing a mechanical lift to obtain the resident weight. 2. Employee left the resident unattended and unsupervised when she went out of the room to get linen for resident's bed. Review of the audit dated 10/17/2023, documented 18 potentially affected residents were audited for safety and supervision while using a mechanical lift. Review of the audit dated 10/17/2023, titled Review of 90 days of incidents' documented there were no injuries or incidents regarding improper use of the mechanical lift in the last 90 days. Review of the Ad-Hoc QAPI meeting on 10/17/2023, documented To remove any areas of concern, The Lakes of [NAME] has initiated and/or completed the following PIP. The facility is now aware of opportunities for improvement related to the use of mechanical lifts. Focus will be on preventing accidents and incidents/supervision/devices, failure to follow SG, and best practices for use of mechanical lift. The QAPI meeting was attended by the Administrator, DON, MD, MDS Coordinators, HR, Business Office Manager, Activities Director, Maintenance Director, Unit Managers, Evening Supervisor, Infection Preventionist/Clinical Educator, COTA, Health Information Manager, and the Social Services Assistant. Review of the root cause analysis and performance improvement plan verified completion on 10/17/2023. Review of the inservice dated 10/17/2023, through 10/20/2023, titled Mechanical Lift with content that included providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents Kardex and care plan prior to care and services being rendered, following plan of care, education on proper transfers to include mechanical lift - resident safe handling with 2 person assist to ensure supervision documented 15 of 16 RNs, 17 of 19 LPNs, and 49 of 51 CNAs received training. One RN, 2 LPNs and 3 CNAs were verified as on paid time off. Review of the Resident Transfer and Ambulation Competency dated 10/17/2023, through 10/20/2023, documented 14 of 16 RNs, 15 of 19 LPNs, and 46 of 51 CNAs completed a mechanical lift competency with return demonstration. During interviews completed on 10/20/2023, the Administrator and DON verified having received education and verbalized understanding to ensure staff are following policy and procedures for transfers, adequate supervision for a resident during the use of a mechanical lift, and safe handling with 2 person assist to ensure supervision. During staff interviews completed on 10/20/2023, 4 RNs, 3 LPNs, and 10 CNAs verified having received education and verbalized understanding of adequate supervision for a resident during the use of a mechanical lift and safe handling with 2 person assist to ensure supervision.

Based on interview and record review the facility failed to ensure wound care treatment was provided as ordered by the physician for 1 of 3 residents, Residents #7. Findings include: Review of Resident #7's medical chart documented the resident was admitted on [DATE] with diagnosis to include fusion of the spine in the lumbosacral region [surgery to connect two or more bones], acute respiratory failure, spinal stenosis and cauda equina syndrome [nerve roots in the lumbar spine are compressed, cutting off sensation and movement]. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 4/29/23 Situation: Skin wound or ulcer. This started on: 04/29/2023. Skin Evaluation: Pressure Ulcer. Wound with full thickness tissue loss. Recommendations of Primary Clinicians: Continue to pack wound with lodoform packing strip and cover with Island dressing. Review of physician's orders dated 4/30/23 read, Right posterior thigh cleanse with NS [normal saline] pat dry, pack with Iodoform packing, cover with petroleum gauze, secure with hydrocolloid dressing, on Monday, Wednesday and Saturday. Review of [Wound Physician Organization's name] Wound Care Physician notes dated 5/3/23 documented wound #2 Stage 4 pressure ulcer right posterior, upper thigh. Wound size 6 cm [centimeters] x 5.8 cm x 1.4 cm. Dressing treatment Santyl, Alginate Calcium with silver 3 x per week for 9 days. Wound Progress: Improved. debrided on this visit. Dated: 5/10/23 wound #2 Stage 4 pressure ulcer right posterior, upper thigh. Wound size 6 cm x 5.8 cm x 2.5 cm. Dressing treatment Betadine gauze sponge non-sterile twice daily 30 days. Wound Progress: Deteriorated. Debrided on this visit. Review of the Treatment Administration Record (TAR) and the physician's orders for the month of May 2023 did not provide documentation of the wound care treatment order change dated 5/3/23 of Santyl, Alginate Calcium with silver 3 x per week or the order change dated 5/10/23 of Betadine gauze sponge non-sterile twice daily. During an interview on 5/17/23 at 2:50 PM the Director of Nursing (DON) stated, we have a rounding nurse that comes in on Wednesday and follows the wound care physician. After the rounding is completed the nurse inputs [wound change] orders in the computer from the Wound Care Physician. The nurse comes in for that reason. The DON stated the wound deterioration may be contributed to the wound care was not followed as ordered by the Wound Care Physician. During an interview on 5/17/23 at 4:05 PM the Wound Care Physician stated, the deterioration of the wound was multifactorial [involving or dependent on a number of factors or causes], care not being done as ordered was a contributor. Review of the facility policy and procedure titled, SG [Standards and Guidelines] Physician and Non-Physician Practitioner Orders issued: 2/1/2002 and revised: 10/24/22 read, Standards: With changing ways in communication it will be the practice of this facility to honor physician's/Licensed Independent Practitioner (LIP) orders in the following ways: Electronic Orders, including, but not limited, to direct entry into the clinical record or electronic order system (or entered in the clinical record by nurse after acknowledged from written order). Electronic Orders (Direct entry into the clinical record) Orders entered into the clinical record following acknowledgement of a written physician's order by a facility staff member. Review of the policy and procedure titled, SG Charting and Documentation issued on 1/1/2006 and revised on 3/27/2021 reads, Standard: It is the standard of this facility that services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Guidelines: 1. Observations, medication administered, services performed, etc., should be documented in the resident's clinical records. 3. Entries into the clinical record should be made by the appropriate staff members. Staff providing care and services to the resident may contribute to the overall documentation in the clinical record in accordance with state and federal laws. Determination of the resident's overall condition may require the collective review of documentation from multiple resources.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles to include the expiration date when applicable in 1 of 3 medication carts observed and failed to ensure all medications were stored in locked compartments to permit only authorized personnel to have access. Findings include: During an observation on 5/15/23 at 10:55 AM of Medication Cart #2 located on the 300 hall with Staff F, Registered Nurse (RN) Unit Manager there were six insulin pens, three insulin Lispro Kwik Pens, one Humalog Kwik Pen, one Insulin Glargine Pen, one Lantus Solostar Pen, that were opened and undated to provide the expiration of the medication. (Photographic evidence obtained). During an interview on 5/15/23 at 11:00 AM Staff F, RN/Unit Manager verified the insulin pens were opened and stated, My expectation is for anyone that opens an insulin pen to date it. During an interview conducted on 5/15/23 at 11:23 AM the Director of Nursing (DON) stated, My expectation is they should be dated [insulin pens]. Review of the policy and procedure titled, Storage revised 08-2020 read, Policy: Medication and biologics are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures I. General Guidance 5. When the original seal of the manufacture's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date open sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. 45576 During an observation on 5/15/2023 at 09:58 AM in Resident #212's room there was a bottle of Nasacort spray and Mentholatum cream on the bedside table. During an interview on 5/15/2023 at 09:58 AM Resident #212 stated, Those are my medications that I use. No one has informed me that I could not have medications at the bedside. During an observation on 5/16/2023 at 08:25 AM in Resident #212's room there was a bottle of Nasacort spray and Mentholatum cream on the bedside table. During an observation on 5/17/2023 at 12:18 PM in Resident #212's room there was a bottle of Nasacort spray and Mentholatum cream on the bedside table. During an interview on 5/17/2023 at 12:26 PM Staff A, License Practical Nurse (LPN) stated, No medications are allowed at the bedside without a physician order for self-administration of medication. During an observation on 5/17/2023 at 12:30 PM with Staff A, LPN of Resident #212's room there was a bottle of Nasacort spray and Mentholatum cream on the bedside table. During an interview on 5/17/2023 at 12:30 PM Staff A, LPN stated, Medications at the bedside are not secured. It is the policy of the facility to not have medications at the bedside unless there is a physician's order and then the medications are secured in the bedside table. We continually check when we enter the rooms and will remove the medications if we observe medications at the bedside and educate the resident. Record review of Resident #212's physician's orders did not contain an order for the resident to self-administer medications. During an interview on 5/17/20230 at 1:23 PM the DON stated, The expectation is for no medications to be at the bedside. If a resident brings in medications, we send them home or remove the medications and lock them up to return them until there is an order received for self-administration or the resident is discharged home. If a resident is capable of self-administering medication, we discuss this at the IDT [interdisciplinary Team] meeting and an order is written for self-administration. If an order is written for self-administration, then the resident can keep medications in their room locked in their bedside table. All staff are responsible to look and ask about unsecure medications in the rooms. We even utilize angel rounds for observations. Record review of Policy and Procedures titled, Standards and Guidelines: SG Medication Storage Policy Number: 12.07.09.055 Issued: 8/1/2006 read, Standard: It will be the standard of this facility to store medications, drugs and biological in a safe, secure and orderly manner. Guidelines: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

Based on observation, interview, and record review the facility failed to ensure residents' medical records were complete and accurate for 3 of 10 records reviewed, Residents #11, #28 and #35. Findings include: 1. Record review of Resident #28's physician orders dated 3/16/2023 read, Heel protectors while in bed every shift. During an observation on 5/15/2023 at 2:28 PM Resident #28 was lying in bed resting. The resident did not have heel protectors. During an observation on 5/16/2023 at 08:07 AM Resident #28 was lying in bed and did not have heel protectors. During an interview on 5/16/2023 at 08:45 AM Resident #28 stated I don't wear them anymore [heel protectors]. During an interview on 5/17/2023 at 08:13 with Staff C, Certified Nursing Assistant (CNA) in Resident #28's room stated, Heel protectors have not been used since the patient received the specialty bed. [Resident #28's name] is lying in the bed with no heels protectors on and heel protectors are not available. Review of the Treatment Administration Record (TAR) for 5/1/2023 through 5/16/2023 documented the resident had heel protectors while in bed every shift. During an interview on 5/17/2023 at 12:45 PM the Director of Nursing stated, The documentation is inaccurate for [Resident #28's name] heel protectors. They were not applied, and the record should not have been documented that they were applied. Staff are to document only if the order is followed and if it is not followed the reason needs to be documented that the order was not followed. 39371 2. During an observation of Resident #35's Peripherally Inserted Central Catheter (PICC) line dressing showed there was a gauze underneath a transparent dressing. The dressing was dated 5/15/23. (Photographic evidence obtained). Review of Resident #35's Treatment Administration Record (TAR) documented the resident's PICC line dressing was changed on 5/10/23 and 5/17/23, there was no additional documentation in the record regarding the PICC line dressing change. During an interview on 5/17/23 at approximately 1:30 PM the Director of Nursing stated, The nurse should have documented the dressing change on 5/15/23, I see that did not happen. This is a documentation issue. Review of the policy and procedure titled, Standards and Guidelines: SG PICC IV [peripherally inserted central catheter intravenous] Line revised: 3/27/21 read, Standards: It will be the standard of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law. Dressing Changes: 2. Dressing changes will be documented in the clinical record. 3. Review of Resident #11's admission record revealed the resident was admitted on [DATE] with the diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, and muscle weakness. Review of Resident #11's TAR for April 2023 reads, Encourage Fluids (thickened) every 4 hours for Recurrent UTIs [urinary tract infection]. Start Date: 05/02/2022 1400 [2:00 PM]. There was no entry on 4/20/2023 at 8:00 AM, 4/26/2023 at 10:00 PM, 4/27/2023 at 2:00 AM, 8:00 AM and 10:00 PM, 4/28/2023 at 2:00 AM and 8:00 AM. Review of Resident #11's TAR for April 2023 reads, Upright after meals every shift. Start Date: 04/30/2022 . Apply house barrier cream to coccyx every shift. Start Date: 04/30/2022 . Observe for S/S [signs and symptoms] of aspiration every shift. Start Date: 04/30/2022 . Monitor for the following signs and symptoms: bleeding gums, nose bleeds unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine. Notify MD [Medical Doctor] if any symptoms present every shift. Start Date: 04/30/2022 . HOB [Head of Bed] elevated greater than 30-45 degrees. Start Date: 04/30/2022. There was no entry on 4/26/2023 and 4/28/2023 for the night shift. Review of Resident #11's TAR for April 2023 reads, Apply moisturizing lotion to whole body excluding skin folds and web spaces two times a day for dry skin. Start Date: 01/12/2023 2100 [9:00 PM]. There was no entry for 4/26/2023 and 4/27/2023 for 9:00 PM. Review of Resident #11's TAR for April 2023 reads, Attach leg strap to secure catheter tubing every shift. Start Date: 03/28/2023 . Catheter Care every shift related to neuromuscular dysfunction of bladder unspecified. Start Date: 05/02/2022. There was no entry for 4/26/2023 and 4/27/2023 for night shift. Review of Resident #11's TAR for May 2023 reads, Encourage Fluids (thickened) every 4 hours for Recurrent UTIs. Start Date: 05/02/2022 1400 [2:00 PM]. There was no entry on 5/3/2023 at 6:00 AM, 5/4/2023 at 2:00 AM and 6:00 AM, 5/6/2023 at 6:00 AM and 6:00 PM, 5/7/2023, 5/8/2023 and 5/11/2023 at 6:00 AM, 5/12/2023 at 6:00 PM and 10:00 PM, and 5/13/2023 at 2:00 AM and 6:00 AM. Review of Resident #11's TAR for May 2023 reads, Upright after meals every shift. Start Date: 04/30/2022 . Apply house barrier cream to coccyx every shift. Start Date: 04/30/2022 . Observe for S/S [signs and symptoms] of aspiration every shift. Start Date: 04/30/2022. There was no entry on 5/7/2023 and 5/12/2023 for the night shift. Review of Resident #11's TAR for May 2023 reads, Monitor for the following signs and symptoms: bleeding gums, nose bleeds unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine. Notify MD if any symptoms present every shift. Start Date: 04/30/2022 . HOB [Head of Bed] elevated greater than 30-45 degrees. Start Date: 04/30/2022. There was no entry on 5/7/2023 and 5/12/2023 for night shift. Review of Resident #11's TAR for May 2023 reads, Apply moisturizing lotion to whole body excluding skin folds and web spaces two times a day for dry skin. Start Date: 01/12/2023 2100 [9:00 PM]. There was no entry for 5/12/2023 for 9:00 PM. Review of Resident #11's TAR for May 2023 reads, Attach leg strap to secure catheter tubing every shift. Start Date: 03/28/2023 . Catheter Care every shift related to neuromuscular dysfunction of bladder unspecified. Start Date: 05/02/2022. There was no entry for 5/7/2023 and 5/12/2023 for night shift. During an interview on 5/18/2023 at 2:30 PM, the Director of Nursing confirmed that the TAR had blanks for Resident #11 and stated that there were documentation issue. Review of the facility policy and procedure titled SG Charting and Documentation issued on 1/1/2006 and revised on 3/27/2021 reads, Standard: It is the standard of this facility that services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Guidelines: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records . 3. Entries into the clinical record should be made by the appropriate staff members. Staff providing care and services to the resident may contribute to the overall documentation in the clinical record in accordance with state and federal laws. Determination of the resident's overall condition may require the collective review of documentation from multiple resources

Based on observations, interviews, and record review, the facility failed to ensure foods placed in the walk-in and reach-in coolers were labeled and dated, failed to ensure food service was conducted in a sanitary manner, and failed to ensure kitchen equipment was maintained in a clean manner. Findings: During an initial tour conducted on 01/03/22 at 9:06 AM with the Certified Dietary Manager (CDM) the following was observed: 1. In the walk-in cooler there was a tray with two plastic wrapped containers of meat without a food label or date. A container of strawberries with a fuzzy substance growing on the product. 2. One of two reach-in coolers had sandwiches without a food label or date. During an observation of the lunch meal service on 1/03/22 beginning at 12:19 PM of all five hallways the food delivery trays were removed from the food carts and then transported down the hall by staff and delivered to the residents' rooms. An observation was made of the trays and showed the cake, pudding, or fresh fruit cups were uncovered on all the room trays that were being delivered. During an interview on 1/03/22 at 12:49 PM the Certified Dietary Manager (CDM) verified the expectations are for foods to be labeled and dated when placed in the cooler, freezer, and dry storage areas. The CDM confirmed that the dessert items were not covered and that policy states that all foods are to be covered when distributed to residents at mealtime. The CDM confirmed there was a fuzzy gray substance on the strawberries and all produce should be observed and disposed of for any signs of spoilage. During an observation on 01/04/22 at 11:23 AM in the kitchen with the CDM, the CDM removed the covering over the meat slicer. The meat slicer had food particles around the blade and between the base that holds bulk food and the slicing blade. During an interview on 1/4/22 at 11:28 AM the CDM confirmed the meat slicer had food particles and debris on it. The CDM stated that a covered piece of equipment would designate that the equipment is clean and ready for use. Review of the policy and procedure titled, Standards and Guidelines; Frequency of Meals Policy #07.07.001 revised 03/04/2021 read: Dietary Staff Unit Food Carts: 4. All foods are covered. Review of the policy titled, Standards and Guidelines; Food Labeling and Dating Policy #07.04.021 revised 03/02/21 read: Standard: Foods are labeled and dated for identification purposes and to ensure they are discarded within acceptable times frames according to HACCP guidelines. Guidelines: 1. Food products that are purchased and brought into the food and nutrition department inventory are dated upon delivery and storage. A permanent marker is used to indicate date opened and date received.

Based on observations, interview, and record review the facility failed to ensure expired medications were not stored with active use medications, failed to label medications according to standards of practice, and failed to ensure medications were stored under proper temperature. (Photographic Evidence Obtained). Findings: During an observation of the 200-unit medication storage room on 1/4/22 at 8:48 AM with the Director of Nursing (DON) and Staff G, Licensed Practical Nurse (LPN) 200 Unit Manager (UM), 16 [MEDICATION(S)] (PPD) solution syringes were expired. One syringe was labeled with an expiration date of 12/16/21, one with an expiration date of 12/18/21, two with an expiration date of 12/19/21, two with an expiration date of 12/21/21, one with an expiration date of 12/22/21, one with an expiration date of 12/24/21, one with an expiration date of 12/28/21, four with an expiration date of 12/30/21, and three with an expiration date of 12/31/21. During an observation of the main medication storage room on 1/4/22 at 8:48 AM with the DON, one PPD solution syringe had an expiration date of 12/3/21. During an interview on 1/4/22 at 9:10 AM the DON confirmed the medications were expired. During an observation of the 300-unit medication storage room on 1/4/22 at 9:13 AM with the DON and Staff H, 300 UM, there was an opened bottle of Acetaminophen 325 mg (milligrams), with an open date of 12/15/2020 and a manufacturer's expiration date of 12/21. During an observation of medication cart #2, 200 unit on 1/4/22 at 9:23 AM with the DON and Staff B, LPN, it showed a bottle of [MEDICATION(S)] Ophthalmic Solution 0.2% which was not labeled with an open date, in a bag there was a bottle of [MEDICATION(S)] 0.005% Ophthalmic Solution with an open date of 11/20/21 and a yellow sticker attached to the bag which read, discard after 6 weeks, also in the bag was an open bottle of Artificial Tears that was not labeled with an open date. The medication cart contained a [MEDICATION(S)] Pen not opened, labeled refrigerate until opened, and an opened [MEDICATION(S)] RU 500 Insulin bottle that was not labeled with an open date. There was a half full container of Assure Platinum blood glucose test strips, not labeled with an opened date. During an interview on 1/04/22 at 9:30 AM Staff B, LPN stated, I am responsible for the cart, and the expectation is to keep the cart organized and medications dated and refrigerated when needed. During an observation of medication cart #1 on the 200 unit on 1/4/22 at 9:38 AM with the DON and Staff C, LPN, showed there was an unopened bottle of [MEDICATION(S)] Insulin 100 units which was labeled refrigerate until opened and two containers of Assure Platinum blood glucose test strips not labeled with opened dates. During an interview on 1/4/22 at 9:45 AM Staff C, LPN confirmed the unopened [MEDICATION(S)] Insulin bottle was labeled refrigerate until opened, and the two containers of Assure Platinum blood glucose test strips did not have an open date on the containers. During an observation of medication cart #2 on the 300-unit on 1/4/22 at 09:53 AM with the DON and Staff E, LPN, it showed a bottle of Ciprofloxin Ophthalmic Solution 0.3% was not labeled with an open date. During an interview on 1/4/22 at 10:00 AM with Staff E, LPN it was confirmed the bottle was not labeled when the eye drops were opened. During an interview on 1/5/22 at 2:40 PM the DON stated, our facility policy does not provide information related to blood glucose strips. The recommendation from corporate was to follow the manufacturer's instructions. The DON verified the blood glucose containers were not dated when opened. Review of policy titled Standards and Guidelines: SG Medication Storage Policy, Number 12.07.09.055, Issued 8/1/2006, Revised 3/27/21 read Standard: It will be the standard of this facility to store medications, drugs and biological in a safe, secure and orderly manner. Guidelines: 3. Drug containers that have missing, incomplete improper or incorrect labels should be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. 10. Medications requiring refrigeration must be stored in a refrigerator located in the drug room or at the nurse's station or other secured location. Review of the Assure Platinum Test strips manufacturer's insert reads: STORAGE AND HANDLING *When you first open the vial, write the date on the vial label.

Based on observation, interview, and record review, the facility failed to ensure the infection prevention and control program was implemented to prevent the possible development of infection. Findings: Review of Resident #2's admission records revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/3/2022 at 10:24 AM, during an observation of Resident #2's catheter drainage bag it showed the drainage bag was hanging on the side of the resident's bed and resting on the floor with one wheel of the bed side table resting on top of the catheter drainage bag. (Photographic evidence obtained). During an interview on 1/3/2022 at 10:25 AM, Resident #2 stated he knew the bag was laying on the floor, but he didn't know if the bag should touch the floor. During an interview on 1/3/2022 at 10:26 AM, Staff A, Licensed Practical Nurse (LPN), verified Resident #2's catheter drainage bag was on the floor with the wheel of the bedside table resting on top of it and stated, We can move the bag to the other side of the bed. On 1/3/2022 at 10:27 AM, Staff A was observed moving the bedside table off of Resident #2's catheter drainage bag, picking the drainage bag up off the floor and then hanging the bag on the opposite side of Resident #2's bed allowing the bottom of the drainage bag to rest on the floor. During an interview on 1/3/2022 at 10:30 AM, the Director of Nursing (DON) verified Resident #2's catheter drainage bag was resting on the floor. The DON stated the catheter drainage bag would need to be replaced due to it having been on the floor and would need to be placed to avoid allowing the drainage bag from touching the floor when hung on Resident #2's bed. Review of the policy and procedure titled, Infection Control Standards and Guidelines: Prevention of Catheter Associated Urinary Tract Infections, read, Guidelines: 11. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.