Every finding on record at Lakeside Rehabilitation and Care Center

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 22 residents (Residents #4, #42 and #45) reviewed for advanced directives. The facility failed to ensure Residents #4, #42 and #45, who were listed as a DNR (Do Not Resuscitate), had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that did not have missing required information. These failures could place residents at risk of not having their end-of-life wishes honored and incomplete records.Findings included: Resident #4 Record review of Resident #4's admission record, dated 06/25/2026, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (lung disease), muscle weakness, diabetes (high blood sugar), Hypertension (high blood pressure), and chronic kidney disease. Advance Directive section revealed - DNR. Record review of Resident #4's physician order summary dated 06/25/2026 revealed an order for DNR dated 11/21/2025. Record review of Resident #4's care plan, dated 03/25/2026, revealed care plan for DNR. Record review of Resident #4's Out of Hospital Do Not Resuscitate form dated 11/13/2025 revealed under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no signature of Person's signature. Resident #42 Record review of Resident #42's admission record, dated 06/25/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorder), muscle weakness, and lack of coordination. Advance Directive section revealed - DNR. Record review of Resident #42's physician order summary dated 06/25/2026 revealed an order for DNR dated 07/13/2020. Record review of Resident #42's care plan, dated 05/11/2026, revealed care plan for DNR. Record review of Resident #42's Out of Hospital Do Not Resuscitate form dated 06/23/2017 revealed under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no signature of attending physician. Resident #45 Record review of Resident #45's admission record, dated 06/25/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include prostate cancer, muscle weakness, dementia (decline in cognitive abilities), depression and hypertension (high blood pressure). Advance Directive section revealed - DNR. Record review of Resident #45's physician order summary dated 06/25/2026 revealed an order for DNR dated 07/18/2024. Record review of Resident #45's care plan, dated 06/22/2026, revealed care plan for DNR. Record review of Resident #45's Out of Hospital Do Not Resuscitate form dated 12/01/2023 revealed, under the Physician's statement, no date. During an interview on 06/25/2026 at 09:52 a.m., the DON stated the SW was responsible for completing resident DNR forms. He stated the SW was currently out of the facility. He stated that the DNR was not valid if missing information. He stated the purpose of a DNR was for residents to be able to express their wishes in the event the cannot. He stated he was not aware the DNRs were missing information. He stated he was not sure if staff were trained. He stated he had no idea what the potential negative outcome could be, but it could be legal. During an interview on 06/25/2026 at 10:36 a.m., the ADM stated the missing signature on Resident #4's DNR was a mistake. He stated when he showed Resident #4 the DNR where she missed signing, Resident #4 agreed to sign it. He stated he would call the doctor and get the signature and date for Resident #42 and #45's DNRs. He stated the purpose of the DNR was to clearly state someone's code status. He stated the SW was responsible for completing the DNR forms and she was not available for interview. He stated he was not aware the DNRs were not completed correctly. He stated the potential negative outcome could be improper identification of code status. Record review of the facility policy titled Advance Directive revised date September 2022 reflected the following: Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Record review of a blank Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Texas Department of State Health Services Instructions for Issuing an OOH-DNR Order revealed the following: . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observation, interviews and record reviews, the facility failed to provide comfortable and safe temperature levels for 1 of 1 dining rooms and 1 of 2 Halls (Hall 2) and a clean and comfortable environment for the 1 of 3 Hallways (front hallway). The facility failed to ensure the temperature for the dining room and Hall 2 did not go above 81 degrees Fahrenheit. The facility failed to ensure the front hallway did not have sticky handrails or a clean appearance on the walls and doors. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.The findings included: During an observation on 06/23/26 at 2:27 PM, the handrail in the front hallway by the business office was noted to have a sticky substance on it. A door in front of Station 2 nursing station labeled Soiled Utility was observed to have black markings on the bottom half of the door. Parts of the wall above the handrail was observed with black markings. The bottoms half of the walls in the front hallway were noted to have black markings from the handrail down to the floor. During the initial pool process on 06/23/26 at 3:20 PM, Hall 2 was observed with the surveyor's thermometer; the inside temperature was 83.2 degrees Fahrenheit. The door was observed open at the end of the hallway and workers were noted with hoses going out the door. No fans or air conditioners were noted in Hall 2 at this time. During an observation on 06/23/26 at 3:34 PM, the hallway leading to the dining room and back door were observed with black markings on the two sides of the hallway frame. The black markings started around the middle and went down towards the floor. During an observation on 06/23/26 at 4:31 PM, the thermostat on the wall in the dining room read 83 degrees Fahrenheit. During a confidential family interview at an undisclosed date and time, one of the family members stated they liked to feed their resident in the front sitting area of the nursing home. The family member stated the dining room was too hot for them to eat in there comfortably. The family member stated it has been hot like this at the nursing home for a while now and it was mainly in the dining room and on Station 2 in the evenings. The family member stated their resident resided on Station 2 and they had to buy several fans for the bedroom to help the resident stay cool. During a confidential resident interview on 06/24/26 at an undisclosed time, the resident stated their room was on Station 2 and it had been getting hot in the evenings. The resident stated they had to buy a fan for their bedroom so they can keep cooler at night. The resident stated staff had been told about the heat and they said the AC was on. During an observation on 06/24/26 at 4:41 PM, the thermostat on the wall in the dining room read 83 degrees Fahrenheit. During an interview on 06/25/26 at 10:43 AM, the MS stated a compressor had been replaced for the AC in the back by the dining room a few weeks ago. The MS stated he felt like the AC had gone back to normal after the compressor was fixed. The MS stated the AC was mainly an older system and when the temperatures start to rise outside, they rise some on the inside. The MS stated none of the residents had complained to him about the heat, only the staff. The MS stated people were constantly going in and out of the dining room door to smoke and the AC won't cool down with the door open. The MS stated the facility had to turn off the AC on Station 2 the other day (06/23/26) and the door remained open at the end of the hall for repairs to be made. The MS stated he did not supply extra fans or AC units to the residents during the time the AC was off and the door at the end of Station 2 Hall was opened. The MS stated the hallways only have 1 vent for the hallway and the resident rooms each have a vent for the AC. The MS stated the hallways do get a little hot if the residents keep the doors to their rooms closed. The MS stated he felt like the AC for the facility was sufficient if all the residents kept their doors open. The MS stated a risk to the residents was overheating. During an interview on 06/25/26 at 11:02 AM, the HSK Director stated the bottom parts of the walls were cleaned with a flat mop daily. The HSK Director stated the bottom half of the walls in the hallways were a different texture and the black markings do not always come off. The HSK Director stated the handrails were cleaned throughout the day. The HSK Director stated she walked through the halls and the resident rooms every day to monitor how her staff were cleaning. The HSK Director stated the staff were trained to clean all areas at the facility, including the walls and the doors. The HSK Director stated a potential risk to the residents was a possible infection with the handrails being dirty. During an interview on 06/25/26 at 1:27 PM, the ADM the facility had a waiver for the central air and heat exchange. The ADM stated the thermostats in the hallways and in the dining room did not have a vent near it and had poor airflow. The ADM stated he did not believe the thermostat reading in the dining room was accurate. The ADM stated the facility did hydration rounds for the residents when the door was open on Station 2 and the AC was off on Tuesday (06/23/26). The ADM stated the facility does its best to maintain the resident rooms to be in regulation for temperature. The ADM stated a potential risk to the residents with the temperature being above 81 degrees Fahrenheit was dehydration. The ADM stated just because the walls have a change in color does not mean the wall was dirty. The ADM stated he expected the staff to clean the handrails and the walls daily. The ADM stated the walls had multiple layers of paint and that could also be a reason why some areas were discolored. The ADM stated he did not believe there was a specific risk to the residents because the facility was clean in his opinion. During an observation on 06/25/26 at 3:57 PM, the thermostat in the dining room read 82 degrees Fahrenheit. The surveyor had a hand thermometer that read 82.5 degrees Fahrenheit by the drinks station in the dining room, and the reading was confirmed by the DM. Record review of the facility document titled, Maintenance Log, dated from 02/25/26 to present, no work orders were noted related to the temperatures.Record review of the facility policy titled, Homelike Environment, with a revised date of February 2021, reflected the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation:.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment.h. comfortable and safe temperatures (71 degrees Fahrenheit - 81 degrees Fahrenheit.Record review of the facility policy titled, Cleaning and Disinfection of Environmental Services, with a revised date of August 2019, reflected the following: Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne pathogens standard.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 of 4 carts (Station 1 Treatment Cart, and Station 2 Nurse Aide Medication Cart) reviewed for medication storage. 1. LVN F failed to ensure the Station 1 Treatment Cart was secured when unattended. 2. MA D failed to ensure the Station 2 Medication Aide Cart did not contain loose pills. These failures could place residents at risk of not receiving prescribed medications as ordered, having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.1. During an observation on 06/23/2026 at 2:26 PM, the treatment cart was in front of the business office unlocked and unattended. No staff or residents were observed around the treatment cart at that time. During an interview on 06/23/2026 at 2:29 PM LVN F stated she went to help a resident and was assisting him to his room. LVN F stated she was supposed to keep her cart locked when she walked away. LVN F stated she was trained to lock her cart but could not remember when. LVN F stated a risk to the residents was they could drink something or squirt something in their mouth. 2. During an observation and interview on 06/23/2026 at 3:39 PM, the Station 2 Medication Aide Cart was observed with MA D. Five (5) loose pills were found in the drawers of the medication cart. MA D placed the pills in a dispensing cup and gave them to the DON for identification. The DON identified the medication as potassium chloride 10 mEq (1 tablet), gabapentin 600 mg (1 tablet), Eliquis 2.5 mg (1 tablet), haloperidol 5 mg (1 tablet), and Lasix 40 mg (1 tablet). The DON took the identified medications to be destroyed. MA D stated the medication cart should not contain loose pills. She stated she was responsible for the cart while she was on duty. MA D stated she usually checked the cart every weekend for loose or expired medications. She stated she was trained on proper medication storage in her medication aide education and at the facility through in-services conducted by nursing administration. MA D stated the medication carts were audited by the pharmacy consultant and checked randomly by nursing administration for secure storage and cleanliness. She stated a potential negative outcome for loose medication on the cart was that a resident could miss a dose of medication or the pharmacy may not refill the medication early. During an interview on 06/25/2026 at 11:10 AM, the ADM stated he was not aware there were loose pills on the cart or that a treatment cart was observed unlocked and unattended. He stated the ADM and DON were responsible for ensuring medications were properly stored and secured. The ADM stated all staff had been trained on medication storage through in-services and pharmacy consultant audits. He stated his expectation of staff was that all medications are properly and securely stored. The ADM stated a potential negative outcome for loose and unsecured medications was injury to a resident up to death due to a resident getting a wrong medication or dose. During an interview on 06/25/2026 at 1:58 PM, the DON stated he was unaware of loose medications on the cart until the medication cart audit was completed. He stated medications should not be loose in the cart and the cart should be secured at all times when unsupervised. He stated the MA's and nursing staff were responsible for assuring medications were properly stored on the carts. The DON stated all staff were trained on proper medication storage through in-services and carts were monitored by the pharmacy consultant conducting cart audits monthly during onsite visits. He stated a potential negative outcome for unsecured medications on the carts was a resident could miss a dose or get a wrong dose. Record review of the facility's policy titled Storage of Medications (Revised November 2020), revealed the following: Policy Statement The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medication.2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in used. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. -The facility failed to ensure foods were properly stored in the refrigerator, freezer and pantry.-The facility failed to ensure the food preparation table, ice chest, walls and fire extinguisher were cleaned. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During the initial tour of the kitchen on 06/23/26 beginning at 9:13 AM the following items were observed:- 1 bag of red grapes in the refrigerator in a gallon-sized bag dated 6/19/26 to 6/25/26 that was not fully sealed.- 1 bag of hamburger buns (8 buns) in the pantry dated 6/16/26 to 6/22/26.- 1 large container of brown sugar in the pantry dated 6/8/26 to 8/8/26 that was not fully sealed.- 1 box/bag of cookies in the freezer not fully sealed.- a dried, white substance could be seen and felt on the side of the food preparation table. - the ice machine in the dining room was observed with black unknown substance on white area inside where the ice was dispensed. During an interview on 06/23/26 at 9:30 AM, the DM stated the facility had received a food order that morning and she had made space in the refrigerator, so the grapes were not fully sealed because she did not check to see if they were when she put them in the bag earlier. The DM stated the cookie box/bag was opened from the wrong side and that was most likely the reason they were not fully sealed in the freezer. The DM stated she had not gone through the pantry yet and that was why the hamburger buns were still on the shelf. The DM stated one of the cooks had used the brown sugar for breakfast and that was why the brown sugar was not fully sealed. The DM stated she did not know what was on the side of the food preparation table and stated the kitchen was cleaned daily. The DM stated the ice machine was last cleaned when the Health Department was in the facility on 4/28/26. The DM stated she was responsible for keeping up with the cleaning of the ice machine. During an observation on a return visit to the kitchen on 06/23/26 at 11:55 AM, a black substance was observed on the bottom half of the wall by the back door and sink and the fire extinguisher by the microwave was noted to have a thick layer of dust. During an interview on 06/25/26 at 10:09 AM, the DM stated she did not know the last time the fire extinguisher had been cleaned, maybe about 6 months ago. The DM stated the walls in the kitchen were last cleaned about 2 months ago when a part of the kitchen was painted. The DM stated she was responsible for ensuring the kitchen was cleaned and food was properly sealed or removed from the shelves if no longer good to use. The DM stated she provided an in-service about once a month for the kitchen staff and she went over any issues and reminders about cleaning. The DM stated a potential risk to the residents was a fly or something could get into the food and the residents could get sick. During an interview on 06/25/26 at 1:27 PM, the ADM stated he expected the food to be stored the proper way to keep food safe and hygienic for the residents. The ADM stated the dietician did a recent inspection of the kitchen on 6/17/26 and he did not know why some food was not stored properly. The ADM stated a potential negative outcome for the residents was a risk for cross-contamination. Record review of the facility policy titled, Food Receiving and Storage, with a revised date of November 2022, reflected the following: Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:.Refrigerated/Frozen Storage1. All foods stored in the refrigerator or freezer are covered, labeled and dated. Record review of the facility policy titled, Sanitization - Kitchen with a revised date of November 2022, reflected the following: Policy Statement: The food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation:1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.2. All utensils, counters, shelves, and equipment are kept clean.10. Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2) and 1 of 1 (Oil Container #1) oil disposal container, in that:The door for dumpster #1 was left open.Dumpster #2 had no plug and was leaking an unidentified substance on the concrete.There was an unidentified substance build-up on top of the oil container #1 and the lid was opened.These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.The findings included: Observation on 06/24/2026 at 11:03 a.m., revealed the facility's dumpster area, which was behind the kitchen had 2 commercial-size dumpsters (#1 and #2). Dumpster #1 had no drain plug. Dumpster #1 had unknown liquid substance draining from the bottom onto concrete in front of the dumpster. Dumpster #2 observed with lid open. Observed oil container #1 with unknown substance build-up on top of container and lid open. Observation on 06/25/2026 at 10:11 a.m., revealed dumpster #1 with an unknown liquid substance draining from the bottom onto the concrete in front of the dumpster. The oil container #1 lid was opened. During an interview on 06/25/2026 at 11:30 a.m., the MS stated that anyone who used the dumpster was responsible for making sure the lid and doors were closed. He stated the dumpster should have a plug. He stated he was not aware the dumpster did not have a plug. He stated kitchen staff did not use the oil disposal container located outside. He stated he was not sure who maintained the oil disposal container. He stated tried to contact a company for removal but was not able to find anyone to service the oil disposal container. He stated the dumpsters were provided by the city. He stated he was not sure what a potential negative outcome would be. During an interview on 06/25/2026 at 11:49 a.m., the ADM stated all staff were responsible for making sure the dumpster doors were closed. He stated staff were trained in properly disposing of trash and oil. He stated the dumpsters were serviced by the city. He stated unless the dumpster was severely damaged the city would not replace the dumpsters. He stated the city would not put a plug in the dumpsters due to it causing the dumpsters to rust out too fast. He stated he had tried multiple times to have the dumpsters serviced but was denied. He stated he was not sure if the kitchen staff used the oil disposal container. He stated the oil disposal should be serviced when you could not put any more oil in it. He stated he was not sure who serviced the oil disposal container, but it should have a sticker on the container. He stated maintenance and the ADM was responsible for having the oil disposal container serviced. He stated he was not aware the lid was left open on the dumpsters or oil disposal container. He stated he was not aware of any negative outcomes. During an interview and observation on 06/25/2026 02:18 p.m., the DM stated all staff were responsible for making sure the dumpster lids were closed. She stated the kitchen staff dumped oil in the oil disposal container weekly. She stated she had tried to close the lid on the oil disposal container but it would not close due to the build-up on top of the container. She stated she was not sure who serviced the oil disposal container. She stated she was told there was a company sticker with company information on the container. Observed white sticker on front of oil disposal container with no company information. She stated all kitchen staff were trained in properly disposing garbage and oil. She stated she was not aware of any potential negative outcome since the dumpsters and oil disposal container was located outside the facility. Record review of the facility policy titled, Food-Related Garbage and Refuse Disposal, revised date October 2017, reflected the following: Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state law.Policy Interpretation and implementation:1. All food waste shall be kept in containers.2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests.6. Storage areas will be kept clean at all times and shall not constitute a nuisance. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in the 1 of 1 kitchen, 1 of 1 dining room, 1 of 2 common areas and 1 of 3 Halls (Hall 2) reviewed for physical environment. The facility failed to provide an effective pest control program for flies in the facility. This failure could place residents at risk for vector-borne diseases.The findings included: During an observation on 06/23/26 at 09:15 AM, during initial tour of the kitchen, a fly was seen in the food pantry area and cooking areas.During an observation on 06/23/26 at 9:36 AM, a resident was observed sitting at a table with a coffee cup in front of her. A fly was observed crawling over the lip of the cup and on the inside of the cup. During an observation on 06/23/26 at 11:41 AM during the puree process in the kitchen, several flies were noted in the kitchen area and were observed landing on the kitchen counters and food preparation areas. During an observation on 06/23/26 at 12:36 pm during the food serving line in the kitchen, several flies were noted landing on the steam table and drinks cart. During a confidential interview at an undisclosed date and time, a confidential resident stated a lot of flies have been noticed at the facility. The confidential resident stated the ADM had been talked to about the flies and fly swatters were supplied to the residents. The confidential resident stated the flies were eating them up. The confidential resident stated pest control had not been seen at the facility for flies. During an observation and interview on 06/23/26 at 4:18 PM, a family member was seen waving flies off of a resident in the sitting area by the dining room. Three to four flies were observed around the resident at that time. The family member stated the flies were in and out of the facility all the time. The family member stated she did not like it when the flies landed on the resident's face. During an observation on 06/24/26 at 2:44 PM, a resident was observed in the sitting area by the dining room, and 3-4 flies were flying and landing on him. During an interview on 06/25/26 at 10:43 AM, the MS stated he has not noticed the flies in the facility. The MS stated no one has told him about the flies being a problem. The MS stated pest control was in charge of things like that. The MS stated it was hot outside and there was an increase in flies everywhere. The MS stated the residents were going in and out of the dining room through the back door and that was why the facility had flies. The MS stated he did not know of a risk for the residents regarding flies. During an interview on 06/25/26 at 1:27 PM, the ADM stated pest control goes out to the facility to provide service, but he was not sure if flies were covered. The ADM stated the door was left open on Station 2 on Tuesday (06/21/26) and that could be how the flies got into the facility. The ADM stated the flies were horrible everywhere right now. The ADM stated they did what they could to keep the flies out of the facility and have even provided some of the residents with a fly swatter. The ADM stated he did not believe the flies were excessive at the facility. The ADM stated a potential risk to the residents was possible cross-contamination due to the fly process of landing on things. Record review of the facility document for Pest Control revealed on 02/26, ants were treated in Rooms 44-47 around the sinks and bed. A signature was noted on 6/8/26 with location, issue, witnessed by and additional description left blank. Record review of the facility policy titled, Pest Control, with a revised date of May 2008, reflected the following: Policy Statement: Our facility shall maintain an effective pest control program.Policy Interpretation and Implementation:1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 18 residents (Resident #59) and 1 of 1 smoking area reviewed for smoking.The facility failed to follow the smoking policy and ensure Resident #59 had a safe smoking evaluation completed.The facility failed to follow smoking policy allowing residents to smoke in non-designated smoking areas.This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking. Findings included:Record review of the admission record for Resident #59, dated 06/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis following cerebral infarction (one-sided weakness after a stroke), muscle weakness (generalized), and lack of coordination.Record review of the admission MDS assessment for Resident #59, dated 06/16/26, revealed a BIMS score of 15, indicating Resident #59's cognition was intact.Record review of the care plan for Resident #59, undated, revealed no Problem area related to smoking.Record review of the electronic medical record assessments for Resident #59 revealed no smoking assessments.During an observation and interview on 06/23/26 at 2:32 p.m., Resident #59 stated he was able to go out to smoke by himself and he was able to keep his smoking supplies on him. A pack of cigarettes was observed in Resident #59's front shirt pocket.During an observation and interview on 06/25/26 at 8:58 a.m., Resident #59 was observed in his room with a pack of cigarettes in his front shirt pocket. Resident #59 stated he did not remember a staff member going out to smoke with him to see how he smoked.During an interview on 06/25/26 at 9:50 a.m., the ADM stated he could not locate a smoking assessment for Resident #59 in electronic medical record. The ADM stated the SW completed the smoking assessments in the facility and she was currently out of the facility and not available by phone. The ADM stated he would look on her desk to see if he could locate a paper copy of a smoking assessment for Resident #59.During an interview on 06/25/26 at 1:27 p.m., the ADM stated the SW was responsible for ensuring a smoking safety screen was performed on a resident upon admission. The ADM stated PCC auto populates a safety smoking screen upon admission for every resident. The ADM stated he did not know why the safety smoking screen was missed for Resident #59. The ADM stated the safety smoking screen could have been done on paper due to poor internet at times, but he could not locate one and the SW was not available by phone. The ADM stated the SW was last trained by the previous SW a week or two prior. The ADM stated a potential risk to the residents was that it could put an unsafe smoker with access to smoking supplies.During an observation on 06/24/2026 at 10:30 a.m. observed unknown resident smoking on back patio by the exit door in the no smoking area.During an observation on 06/24/2026 at 11:06 a.m. observed no smoking signs above the windows on the back patio. Observed ashtray on back patio between the windows with no smoking signs. Observed red trash can on back patio in the no smoking area.During an observation on 06/25/2026 10:09 a.m. observed resident smoking on back patio by the exit door in the no smoking area.During an interview on 06/25/2026 at 11:49 a.m., the ADM stated the designated smoking area was out the dining room door on the back patio to the left of the metal gate. He stated the facility has several residents who were allowed to smoke unsupervised. He stated the facility has had meetings with the residents about the designated smoking area. He stated the last meeting was held on 03/20/2026. He stated all smoking materials should be on the left side of the metal gate. He stated there were signs posted for smoking and non-smoking areas. He stated he made rounds daily and moves any smoking items found in non-designated areas to the back patio. He stated the residents placed the ashtrays in the non-designated smoking areas. He stated, There is not a 24/7 smoking tenant to monitor smoking. He stated maintenance cleaned the back patio area daily. He stated he was not aware of a potential negative outcome but believed smoking had to be 25 feet from any exit door. Record review of the facility policy titled, Smoking Policy - Resident, revised date August 2022, reflected the following: Policy Statement - This facility shall establish and maintain safe resident smoking practices.Policy Interpretation and Implementation.1. Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances.6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: .d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation) .8. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 2 of 22 resident (Resident #6 and #45) reviewed for PRN psychotropic medications, in that: Resident #6 continued to have a PRN order for Lorazepam 2 MG/ML after 14 days without a stop date. Resident #45 continued to have a PRN order for Lorazepam 1 MG after 14 days without a stop date. This failure could result in residents receiving antipsychotic medications when contraindicated and could result in residents experiencing adverse drug reactions.The findings include: Resident #6 Record review of Resident #6's face sheet, dated 06/25/2026, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (cognitive loss), diabetes (high blood sugar), and hypertension (high blood pressure). Record review of Resident #6's quarterly MDS, dated [DATE], reflected Resident #6's BIMS score was 00 which indicated Resident #6 had severely impaired cognitive impairment. The MDS further reflected Resident #6 had diagnoses of Alzheimer's disease and anxiety disorder. Record review of Resident #6 care plan, dated 03/04/2026, reflected a problem for anxiety with interventions to administer medications as ordered. Record review of Resident #6's physician order summary dated 06/23/2025reflected the following orders: Lorazepam oral concentrate 2mg/ml, give 0.25 ml by mouth every hour as needed for agitation/anxiety, dated 09/09/2025 with no end date. Lorazepam oral tablet 0.5mg, give 0.5mg by mouth every 6 hours as needed for agitation/anxiety, dated 09/09/2025 with no end date. Record review of Resident #6's PRN MAR reflected the following: Lorazepam Oral Concentrate 2 mg/ml give 0.25 ml by mouth every hour as needed for agitation/anxiety. Start Date 09/10/2025. Medication administered on 06/01/2026, 06/03/2026 and 06/17/2026. Lorazepam Oral Tablet 0.5mg by mouth every 6 hours as needed for agitation/anxiety. Start Date 09/09/2025. Medication administered on 06/09/2026, 06/13/2026 and 06/14/2026. Resident # 45 Record review of Resident #45's admission record, dated 06/25/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include prostate cancer, muscle weakness, dementia (decline in cognitive abilities), depression and hypertension (high blood pressure). Record review of Resident #45's comprehensive MDS, dated [DATE], reflected Resident #45's BIMS score was a 08 which indicated Resident #45 had moderate cognitive impairment. Record review of Resident #45 care plan, dated 03/04/2026, reflected a problem for anxiety with interventions to administer medications as ordered. Record review of Resident #45's physician order summary dated 06/23/2025reflected the following orders: Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 mg by mouth every 4 hours as needed for anxiety, dated 11/14/2024 with no stop date. Record review of Resident #45's PRN MAR reflected the following: Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 mg by mouth every 4 hours as needed for anxiety, start date 11/14/2026. No medication was administered for the month of June. During an interview on 06/26/2026 at 09:52 a.m., the DON stated Residents #6 and #45 were on hospice services and did not need a stop date for the prn psychotropic medications. He stated he did not have additional documentation to support the need for the past 14 days. He stated he was not aware prn psychotropics needed a stop date if the resident was on hospice services. He stated all nursing staff had been trained on prn psychotropic. He stated the nursing staff was responsible for making sure PRN psychotropic medications had stop dates. He stated he added stop dates to Resident #6 and #45 lorazepam prn orders. He stated he had also started an in-service for nurses to make sure the order has a 14 day stop date for all prn psychotropic medications. He stated the potential negative outcome could be unnecessary prn psychotropic medications. During an interview on 06/26/2026 at 10:40 p.m., the ADM stated PRN psychotropic medications were for residents with behaviors. He stated he was not aware Residents #6 and #45 did not have a stop date on the prn psychotropic medications. He stated the DON and nursing staff were responsible for making sure the order has a 14 day stop date when the order is received. He stated all staff had been trained on PRN psychotropic medications. He stated the potential negative outcome could be residents being over medicated. Record review of the facility policy titled Psychoactive Medications revised date 07/22 reflected the following: Policy: Residents will not receive medications that are not clinically indicated to treat a specific condition.15. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record.16. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order.

Based on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 18 residents (Resident #59) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #59 for tobacco use on his annual MDS assessment. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.Findings included: Record review of the admission record for Resident #59, dated 06/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis following cerebral infarction (one-sided weakness after a stroke), muscle weakness (generalized), and lack of coordination.Record review of the admission MDS assessment for Resident #59, dated 06/16/26, revealed a BIMS score of 15, indicating Resident #59's cognition was intact. The MDS further revealed in Section J that Resident #59 was marked No for Current Tobacco Use.Record review of the care plan for Resident #59, undated, revealed no problem area related to smoking.Record review of the electronic medical record for Resident #59 revealed no safe smoking assessments.During an observation and interview on 06/23/26 at 2:32 PM, Resident #59 stated he was able to go out to smoke by himself and he was able to keep his smoking supplies on him. Observed a pack of cigarettes in Resident #59's front shirt pocket. Resident #59 stated he wanted to come to this facility because of their smoking policy and his previous facility was changing their smoking policies and he did not like that.During an interview on 06/25/26 at 9:53 AM, the MDS Coordinator stated she had completed the admission MDS for Resident #59. The MDS Coordinator stated she was not aware that Resident #59 smoked. The MDS Coordinator stated she checked the resident's chart for a safe smoking assessment and did not see one. The MDS Coordinator stated due to the location of her office and the door to her office being closed most of the time, she was not able to see which residents went outside to smoke. The MDS Coordinator stated she relied on a smoking assessment to be performed for her to know if a resident smokes or not. The MDS Coordinator stated it had been a long time since she was last trained on MDS accuracy. The MDS Coordinator stated a risk to the resident was their care could be missed. The MDS Coordinator stated odds were the care plan was also not completed correctly due to the MDS being inaccurate and that was where the nursing department got their information on how to care for a resident. During an interview on 06/25/26 at 1:27 PM, the ADM stated the MDS Coordinator was responsible for ensuring the MDS was an accurate snapshot in time of care for a resident. The ADM stated the MDS Coordinator was last trained last week sometime, maybe Tuesday (6/16/26) or Wednesday (06/17/26) but he could not remember exactly. The ADM stated he did not know why the MDS Coordinator missed the smoking status for Resident #59. The ADM stated a risk to the resident was that it could inaccurately represent a picture of the resident at that time. Record review of the facility policy titled, Comprehensive Assessments, with a revised date of March 2022, reflected the following: Policy Statement: Comprehensive assessments are conducted to assist in developing person-centered care plans. Policy Interpretation and Implementation:1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual.Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025 revealed the following:Section J: Health Conditions.J1300: Current Tobacco Use:Item Rationale - Health-related Quality of Life-The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life.Steps for Assessment -Ask the resident if they used tobacco in any form during the 7-day look-back period.If the resident states that they used tobacco in any form during the 7-day look-back period, code 1, yes. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 18 residents (Resident #59) reviewed for care plans. The facility failed to develop a care plan for Resident #59 related to smoking. This failure could place residents at risk of not receiving the care required to meet their individual needs. Findings included: Record review of the admission record for Resident #59, dated 06/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis following cerebral infarction (one-sided weakness after a stroke), muscle weakness (generalized), and lack of coordination. Record review of the admission MDS assessment for Resident #59, dated 06/16/26, revealed a BIMS score of 15, indicating Resident #59's cognition was intact. Record review of the care plan for Resident #59, undated, revealed no problem area related to smoking. Record review of the electronic medical record for Resident #59 revealed no smoking assessments. During an observation and interview on 06/23/26 at 2:32 PM, Resident #59 stated he was able to go out to smoke by himself and he was able to keep his smoking supplies on him. A pack of cigarettes was observed in Resident #59's front shirt pocket. During an interview on 06/25/26 at 11:37 AM, the DON stated all of the staff pitched in on the care plans. The DON stated the care plans were a work in progress. The DON stated a smoking care plan was missing for Resident #59 because the care plans were a work in progress. The DON stated there was no risk to the resident if he was safe to smoke unsupervised. During an interview on 06/25/26 at 1:27 PM, the ADM stated he expected the care plan to be an accurate reflection of the care for a resident. The ADM stated he did not know why Resident #59 was missing a care plan for smoking. The ADM stated a risk to the resident was there could be possible negative outcomes towards the resident. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of March 2022, reflected the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interviews and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 2 (Resident #43 and Resident #49) of 22 residents reviewed for comprehensive care plan revisions.1. The facility failed to ensure Resident #43's comprehensive care plan was updated with the most current information for the resident's smoking status. 2. The facility failed to ensure Resident #49's comprehensive care plan was updated with the most current information for the resident's smoking status. These failures could put residents at risk of not receiving the appropriate care, services, or treatments needed to maintain health.1. Record review of the admission record for Resident #43, dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 01/16/2022. Resident #43 had diagnoses which included: atherosclerotic heart disease (a heart condition affecting blood supply to the heart), congestive heart failure (a heart condition where the heart is too weak to pump blood efficiently), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy and activity levels), and Type II diabetes mellitus (a metabolic condition affecting blood sugar levels). Record review of the quarterly MDS assessment for Resident #43, dated 06/12/2026, revealed a BIMS score of 15, indicating the resident was cognitively intact. Record review of the Smoking Safety Screen for Resident #43, dated 04/13/2026, revealed Resident #43 was safe to smoke without supervision. Record review of the care plan for Resident #43, undated, revealed, [Resident #43] is a supervised smoker. [Resident #43] will smoke with supervision, with an initiation date of 09/26/2024 and revised date of 03/24/2026. During an interview on 06/23/2026 at 9:46 AM, Resident #43 stated she was unsupervised while smoking at the facility. She stated she was aware of smoking times for residents who smoked with a staff member, but she preferred to go out to smoke alone when other smokers were not present. Resident #43 stated she kept her smoking supplies with her in her room and a safe smoking assessment was done on her within the past year. 2. Record review of the admission record for Resident #49, dated 06/24/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection (bacterial infection in the urinary system), muscle weakness, and other lack of coordination. Record review of the admission MDS assessment for Resident #49, dated 12/28/2025, revealed Resident #49 had a BIMS score of 14 indicating his cognition was intact. The MDS further revealed Resident #49 currently used tobacco. Record review of the Smoking Safety Screen for Resident #49, dated 04/27/2026, revealed Resident #49 was safe to smoke with supervision. Record review of the care plan for Resident #49, undated, revealed, Focus: Smoker: [Resident #49] is a smoker. He is safe to smoke unsupervised, with an initiation and revised date of 01/08/2026. During an interview on 06/25/2026 at 11:10 AM, the ADM stated he was not aware Resident #43's care plan had not been updated to reflect that the resident was safe to smoke unsupervised. The ADM stated the care plan was utilized by all direct-care staff and IDT members and should reflect the most current status of the resident During an interview on 06/25/2026 at 11:37 AM, the DON stated all of the staff pitched in on the care plans. He stated any IDT member could make changes to the care plan. The DON stated the care plans were a work in progress. The DON stated originally Resident #49 was safe to smoke without supervision and now he was not. He stated he was unsure why Resident #43's care plan had not been updated to reflect that she no longer required supervision to smoke. The DON stated a potential negative outcome for failure to update and revise care plans was that staff may not be aware of changes that were made to a resident's plan of care. During a follow up interview on 06/25/2026 at 1:27 PM, the ADM stated the care plans were revised as needed and quarterly. The ADM stated Resident #49's smoking status recently changed and that was why his care plan had not been updated yet. The ADM stated a possible risk to the residents was they could have possible negative outcomes. During an interview on 06/25/2026 at 4:21 PM, the ADM stated the facility did not have a specific policy for the revision of care plans. He stated the only policies relating to care plans had been provided to the survey team by the facility. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered (Revised March 2022) revealed: PolicyA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition;.d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #49) reviewed for smoking. The facility failed to ensure Resident #49's smoking items were kept at the nursing station and he received adequate supervision while smoking. This failure could place the residents at risk of inadequate supervision, accidents, and burns which could result in injury.Findings Included: Record review of the admission record for Resident #49, dated 06/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection (bacteria in urinary system), muscle weakness, and other lack of coordination. Record review of the admission MDS assessment for Resident #49, dated 12/28/25, revealed Resident #49 had a BIMS score of 14 indicating his cognition was intact. The MDS further revealed Resident #49 currently used tobacco. Record review of the Smoking Safety Screen for Resident #49, dated 04/27/26, revealed Resident #49 was safe to smoke with supervision. Record review of the care plan for Resident #49, undated, revealed, Focus: Smoker: [Resident #49] is a smoker. He is safe to smoke unsupervised, with an initiation and revised date of 01/08/2026. During an observation on 06/23/26 at 9:40 AM, Resident #49 was observed propelling his wheelchair out to the smoking area with a pack of cigarettes in one hand. During an observation and interview on 06/23/26 at 9:48 AM, Resident #49 was observed putting trash from the cigarette box into a metal ash tray in front of him. Resident #49 finished his cigarette and was observed putting out his cigarette on top of the cigarette box trash in the metal ash tray. Resident #49 stated he was allowed to put trash in the metal ash tray or in the red trash can and the staff take it out to the dumpster. Resident #49 stated he was allowed to keep his cigarettes and lighter on him. No staff members were observed in the smoking area during this time. Interview on 6/25/26 at 11:37 AM, the DON stated Resident #49 last had a smoking evaluation 04/27/26 and it showed that he was safe to smoke with supervision. The DON stated he did not know how Resident #49 was supplied cigarettes and a lighter. The DON stated maybe it was missed because he was originally ok to smoke unsupervised and now, he was not. The DON stated all of the staff were responsible for ensuring Resident #49 was supervised for smoking. The DON stated a potential risk for the resident was burns. Interview on 06/25/26 at 1:27 PM, the ADM stated the last smoking assessment for Resident #49 was performed by him on 04/27/26 and it showed that Resident #49 was safe to smoke with supervision. The ADM stated the smoking assessment was completed 9 days after Resident #49's first smoking assessment that showed he was safe to smoke without supervision. The ADM stated he did not know why he completed another smoking assessment on 04/27/26 that showed a difference in Resident #49's smoking status. The ADM stated according to the most recent smoking assessment for Resident #49, his cigarettes and lighter should be kept locked in the nursing cart. The ADM stated he did not know why Resident #49 had his smoking supplies on him and stated maybe the resident purchased the supplies by himself. The ADM stated no burns or burn marks on clothing had been seen on Resident #49. Record review of the facility policy titled, Safety and Supervision of Residents with a revised date of July 2017, reflected the following: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation:.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:.d. Smoking. Record review of the facility policy titled, Smoking Policy - Residents with a revised date of August 2022, reflected the following: Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation:.6. Resident Smoking status is evaluated upon admission. If a smoker, the evaluation includes:.d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).14. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco.except under direct supervision.

Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 2 residents fed by gastrostomy tube (g-tube) (Resident #42), in that: The facility failed to ensure Resident #42's feeding pump was hooked up and infusing at the time ordered by the physician. This failure could result in weight loss and dehydration in residents with a g-tube.The findings included: Record review of the admission record for Resident #42, dated 06/24/26, revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: athetoid cerebral palsy (condition caused by early brain damage), muscle wasting and atrophy (muscles shrink and weaken) and gastrostomy status (g-tube). Record review of the comprehensive MDS assessment for Resident #42 dated 11/05/25 revealed Resident #42 was assessed by staff, and his mental status was severely impaired- he never/rarely made decisions. The MDS further documented Resident #42's Nutritional Approach While a Resident was feeding tube and the proportion of total calories the resident received through a tube feeding was 51% or more. Record review of the current care plan for Resident #42, undated, revealed a problem area for: [Resident #42] is at risk for dehydration related to NPO status, PEG feedings and dependent on staff for all nourishment and hydration. Date Initiated 07/08/2020. Resident #42's care plan revealed another problem area for: [Resident #42] requires nutrition via PEG tube. Jevity 1.5 at 85 mL/hr x 15 hours with H2O at 68 mL/hr x 15 hours via pump. To start at 1500[3pm] and Off at 0600[6am]. NPO diet. Revised on 01/14/2026. Record review of the order summary report for Resident #42, dated 06/24/26, revealed an order for: Jevity 1.5 at 85 mL/hr X 15 hours with H2O at 68 mL/hr X 15 hours via pump. TO START at 1500 AND OFF at 0600. in the evening Place on feeding with a start date of 06/24/26. Record review of the Weight Summary for Resident #42 revealed the following: 4/5/26 - 106.2 LBS, 5/4/26 - 108.0 LBS, and 6/4/26 - 105.2 LBS. During an observation on 06/24/26 at 3:07 PM, Resident #42 was not in his room and his feeding pump was observed next to the bed and was off. During an interview on 06/24/26 at 3:41 PM, LVN C stated Resident #42 normally returned from the Day Center after 4pm daily. During an observation on 06/24/26 at 4:16 PM, 2 CNA's were observed putting Resident #42 back in bed via Hoyer-lift. The feeding pump was next to the bed and was turned off at that time. During an interview on 06/24/26 at 4:18 PM, the ADM stated Resident #43 usually returned to the facility between 4:15 PM and 5:15 PM daily, it depended on what time the bus dropped him off. During an observation and interview on 06/24/26 at 4:42 PM, LVN C was observed in Resident #42's room with a gown and gloves on. LVN C stated she had just changed the dressing for Resident #42's g-tube site and was hooking him up to his feeding at this time. Attempted phone interview on 06/25/26 at 8:40 AM, the Dietician did not answer. A voicemail was left with a call back number. During an interview on 06/25/26 at 9:01 AM, the ADON stated she was covering the shift for Station 2. The ADON stated the city bus was the main transportation for Resident #42. The ADON stated depending on how many stops they had, sometimes the bus dropped Resident #42 off late to the facility. The ADON stated he was always back to the facility by 6 PM. The ADON stated she has not noticed any weight loss or dehydration signs for Resident #42. The ADON stated he looks pretty much the same. The ADON stated the facility had an hour before and an hour after the time that was ordered to put Resident #42 on his feeding. The ADON stated she did not know a possible risk to Resident #42 with his feeding being hooked up late. During an interview on 06/25/26 at 11:37 AM, the DON stated Resident #42 normally got back to the facility from the Day Center a little after 4 PM daily and that was why he did not get hooked up to his feeding at 3 PM. The DON stated Resident #42 had not had a lot of weight fluctuations recently. The DON stated staff were trained to follow physician's orders regarding g-tube nutrition, but he did not know the last time. The DON stated a possible risk to the residents was that it could lead to weight loss or a UTI. During an interview on 06/25/26 at 1:27 PM, the ADM stated he expected a resident to be fed according to proper nutrition and to follow the dietician's recommendations. The ADM stated he felt like Resident #42 was getting the proper nutrition and hydration, even though Resident #42 was not getting the total 15 hours of formula and hydration as ordered. The ADM stated a possible negative outcome for the resident was losing weight if they received all nutrition through the g-tube. Record review of facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a revised date of November 2018, reflected the following: Purpose: The purpose of this procedure is to provide a guideline for the use of a pump of enteral feedings.Preparation:1. Verify that there is a physician's order for this procedure. Record review of the facility's policy titled, Resident Hydration and Prevention of Dehydration, with a revised date of October 2017, reflected the following: Policy Statement: This facility will strive to provide adequate hydration and to prevent and treat dehydration.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 22 residents reviewed for unnecessary medication (Resident #10).The facility did not monitor Resident #10 for side effects of the anticoagulation medication Apixaban.This failure could place the residents at risk for adverse consequences of medication.Findings included:Record review of Resident #10's face sheet, dated 06/24/2026, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include quadriplegia (paralysis all 4 extremities), seizures (episode of abnormal [NAME] activity), and hypertension (high blood pressure).Record review of Resident #10's Quarterly MDS Assessment, dated 04/24/2026, revealed Resident #10 had a BIMS score of 15, which revealed the resident's cognition was intact. Section N - Medications revealed Resident #10 received anticoagulant during the last 7 days. Record review of the physician orders dated 06/24/2026 revealed Resident #10 was prescribed 5mg apixaban by mouth two times a day. The orders did not address monitoring the anticoagulant.Record review of a care plan dated 01/07/2026 revealed Resident #10 was on anticoagulant therapy with interventions to monitor/document/report signs or symptoms of anticoagulant complications.Record review of MAR dated 06/24/2026 revealed Resident #10 received 5mg apixaban two times a day as ordered from 06/01/2026 to 06/23/2026. Record review of Resident #10 electronic medical record did not indicate the nurses documented monitoring of side effects of anticoagulant daily with medication administration.During an interview and record review on 06/25/2026 at 09:52 a.m., the DON stated the purpose of monitoring anticoagulation medication was to make sure there was no uncontrolled bleeding. He stated he was not aware the resident did not have an order for monitoring. He reviewed Resident #10's EMR and stated there was no order for monitoring. He stated the order was not added when the order for apixaban was ordered. He stated all staff have been trained to add anticoagulant monitoring when medication was ordered. He stated he was responsible for checking new orders. He stated the potential negative outcome could be uncontrolled bleeding.During an interview on 06/25/2026 at 10:20 a.m., the ADM stated the purpose of anticoagulant monitoring was to ensure that if something happened the resident did not bleed out. He stated he was not aware Resident #10 did not have an order for anticoagulant monitoring but was aware that medication needed monitoring. He stated the DON was responsible for making sure orders were put in the EMR. He stated he was not sure what monitoring system was in place, but he was sure nursing had a system. He stated the potential negative outcome could be resident injury or death.Record review of the facility policy titled, Anticoagulation - Clinical Protocol, revised date 11/2018 reflected the following: .5. The staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 10.34 percent based on 3 errors out of 29 opportunities, which involved 2 (Resident #8 and Resident #43) of 3 residents reviewed for medication administration. 1. MA E failed to give Resident #43's dose of the medication Chlorhexidine Gluconate at the ordered time, due to not having the medication available, resulting in a missed dose. 2. MA E failed to give Resident #8's doses of the medications Apixaban and Propranolol Hydrochloride at the ordered time, resulting in a late dose for each medication. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and a decline in health.1. Record review of Resident #43's admission Record dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 01/16/2022. Resident #43 had diagnoses which included: atherosclerotic heart disease (a heart condition affecting blood supply to the heart), congestive heart failure (a heart condition where the heart is too weak to pump blood efficiently), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy and activity levels), and Type II diabetes mellitus (a metabolic condition affecting blood sugar levels). Record review of Resident #43's Quarterly MDS assessment, dated 06/12/2026, revealed a BIMS score of 15, indicating the resident was cognitively intact. Record review of Resident #43's current physicians orders revealed an order with a start date of 04/11/2025 for Chlorhexidine Gluconate Solution give 30 ml by mouth two times a day for mouth wash. During a medication administration observation and interview on 06/24/2026 at 8:21 AM for Resident #43, MA E was unable to give the medication Chlorhexidine Gluconate mouth wash due to the medication being unavailable on the medication cart or in the medication room. She stated she was unsure why the medication was not in the facility. MA E stated the medication should be available for dispensing and had been ordered but must not have been delivered yet by the pharmacy. MA E stated she would check with the pharmacy for the status of the reordered medication once she completed her medication pass. She stated if reordered medications were not delivered timely by the pharmacy, the policy was to inform the charge nurse who would check with the pharmacy. During an interview on 06/24/2026 at 8:28 AM, Resident #43 stated she had used Chlorhexidine Gluconate mouthwash, and it was prescribed by her doctor. She stated the MA or nurse brought the mouthwash to her during medication pass. Resident #43 stated she did not recall the date she last used the prescribed mouthwash and stated, sometimes I tell the nurse I don't want it that day because I don't really like it. Resident #43 stated she preferred a different mouthwash and was planning to tell her doctor she wanted to change to the preferred mouthwash the next time she saw him. 2. Record review of Resident #8's admission Record dated 06/23/2026 revealed a [AGE] year-old female with an original admission date of 07/18/2022. Resident #8 had diagnoses which included: atrial fibrillation (a common heart arrhythmia), muscle weakness, and hypertension (high blood pressure). Record review of Resident #8's Quarterly MDS assessment, dated 05/18/2026, revealed a BIMS score of 09, indicating the resident had moderate cognitive impairment. Record review of Resident #8's current physicians orders revealed an order with a start date of 03/08/2024 for Apixaban oral tablet 2.5 mg. Give one tablet two times a day related to atrial fibrillation. Further review revealed an order with a start date of 10/12/2022 for Propranolol HCL tablet 20 mg. Give one tablet by mouth in the morning related to hypertension. Record review of Resident #8's June 2026 MAR revealed Apixaban oral tablet 2.5 mg and Propranolol HCl tablet 20 mg were each ordered to be administered at 7:00 AM. During a medication administration observation and interview on 06/24/2026 at 9:25 AM for Resident #8, MA E dispensed one Apixaban 2.5 mg tablet and one Propranolol HCl 20 mg tablet and administered the medications to Resident #8, which resulted in both doses being late. MA E stated the medications showed late due to being outside the one-hour window from the time the medication was ordered. She stated the medications were given a little over an hour late due to getting behind on medication pass this morning. She stated, per policy, she would let nursing administration know about the error so notification could be made to the provider. During an attempted interview on 06/25/2026 at 1:56 PM, a telephone call was placed to the facility medical director. There was no answer and a voicemail was left requesting a returned call. During an interview on 06/25/2026 at 3:58 PM, the DON stated he was not aware until after the observed medication pass that physicians orders had not been accurately followed. He stated all staff were trained on accurate medication administration. The DON stated the facility utilized rounds and competency checks for monitoring and training of accurate medication administration. He stated nursing administration was responsible for ensuring accurate and timely medication administration. He stated the pharmacy consultant conducted monthly competency checks for medication administration. He stated medication errors were reported to the provider and noted in the health record. The DON stated a potential negative outcome for failure to follow physicians orders during medication administration was a resident could be injured or suffer harm. During an interview on 06/25/2026 at 3:58 PM, the ADM stated he was not aware that physicians' orders for medications had not been accurately followed until after the medication observation was conducted. He stated nursing administration was responsible to assure staff were administering medications accurately and according to physicians' orders. The ADM stated all nursing staff and MAs were trained on accurate medication administration. The ADM stated the medical director would assist the facility to establish more efficient medication administration times to avoid potential negative outcomes. During a telephone interview on 06/26/2026 at 5:12 PM, MA E stated it was the responsibly of the MA's and nurses to assure medications were available in the facility and given on time, according to physicians orders. She stated when a medication was ordered at a certain time, she had one hour before that time and one hour after that time to be in compliance with the medication administration policy. She stated she did administer Resident #8's medications a little late during the medication pass observation. MA E stated occasionally medications were late due to having to go from one side of the facility to the other and changing carts, which was time consuming. She stated she passed all the scheduled medications in the facility, and she got behind sometimes when she got interrupted or had to wait on a resident to administer their medications. MA E stated the facility utilized liberal med pass, on some medications, meaning she had a longer window to pass those medications, which made it easier for her to administer medications on time. She stated the charge nurses also administered some of the medications, such as insulin, PRN narcotics and eye drops. MA E stated the MAs were allowed to order some medications on the computer system. She stated if the medications were not delivered by the next day, the MA would inform the charge nurse who would then follow up with the pharmacy. MA E stated she was trained on accurate medication administration during her MA training and at the facility through observations and in-services conducted by nursing administration. She stated a potential negative outcome for failure to administer medications according to physicians orders was that a resident could have changes in blood pressure, have an increased in pain, or have heartburn if a medication was not given before a meal. During a telephone interview on 06/30/2026 at 4:54 PM, the medical director stated his expectation for ordered medication was that the medication was given within one hour prior to or one hour following the scheduled administration time. He stated he did not have concerns for a resident receiving Propranolol or Apixaban medications approximately 1.5 hours late. He stated a potential negative outcome for failure to administer medications according to physicians' orders would depend on the medication, but it was important to follow the orders for timing and accuracy of all medications. Record review of the facility policy titled Administering Medications (Revised April 2019) revealed: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #42) reviewed for infection control. RN A failed to wear proper PPE (a gown) when providing wound care and administering tube feeding through a PEG tube) for Resident #42 who was on EBP. These failures could place residents at risk for the spread of infection and cross contamination.Record review of Resident #42's admission record dated 06/25/2026, revealed a [AGE] year-old male with an original admission date of 07/16/2012. Resident #42 had diagnoses which included: athetoid cerebral palsy (a neurological condition caused by brain damage before or during birth), gastrostomy (a surgical procedure that creates a small opening through the abdominal wall into the stomach), and muscle weakness. Record review of Resident #42's Quarterly MDS assessment, dated 05/08/2026, revealed - Section C - BIMS score not performed as resident was rarely understood. Section - K - Swallowing and Nutritional Status revealed resident had a feeding tube. Record review of Resident #42's current physicians orders revealed an order with a start date of 05/21/2026 for Wound Care: PEG Tube: Cleanse area surrounding PEG tube with NS or wound cleanser, pat dry and apply treatment as ordered. Further review revealed an order with a start date of 06/24/2024 for tube feeding to run 15 hours per day via pump. An order with a start date of 02/04/2025 revealed: Enhanced Barrier Precautions for G-Tube/Wounds. Gloves and Gown to be worn when providing: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Record review of Resident #42's care plan dated 05/22/2026, revealed: [Resident #42] requires nutrition via PEG tube. During an observation and interview on 06/23/2026 at 4:17 PM of wound care and PEG (a feeding tube placed through the abdominal wall into the stomach) tube feeding administration for Resident #42, RN A was observed entering the room for Resident #42 with supplies for wound care. A cart with PPE was observed in the hallway next to Resident #42's door. An Enhanced Barrier Precaution sign was observed hanging next to the door of Resident #42's room. RN A donned gloves prior to providing ordered wound care to the area surrounding the PEG tube site. RN A did not don a gown prior to providing wound care. RN A then provided Resident #42's tube feeding via PEG tube, according to orders. RN A donned gloves and provided the tube feeding without donning a gown prior to the procedure. RN A stated she should have worn a gown prior to providing wound care and tube feeding administration for Resident #42. She stated she was rushing and failed to put her gown on. RN A stated she was trained on EBP through in-services conducted by nursing administration, and she last received training on 06/17/2026. RN A stated the purpose of EBP was to prevent the spread of infection and PPE should be utilized when doing direct care of any resident who has a device such as a catheter or feeding tube or wounds. RN A stated a potential negative outcome for failure to wear proper PPE while performing direct care on a resident who was on EBP was cross-contamination and infection. During an interview on 06/25/2026 at 11:10 AM, the ADM stated he was made aware that a staff member conducted direct care on a resident on EBP without utilizing a gown. He stated the purpose of EBP was to protect residents and staff from the spread of infection. The ADM stated all staff were trained on EBP upon hire and through ongoing training in the facility. He stated, as ADM, he was ultimately responsible to ensure staff were following proper EBP protocol and nursing administration was responsible to ensure the protocol was being followed as well. The ADM stated a potential negative outcome for failure to use proper PPE for a resident who was on EBP was the spread of infection that could cause harm to residents or staff. During an interview on 06/25/2026 at 1:58 PM, the DON stated he was made aware by RN A that she failed to wear proper PPE while performing direct care for Resident #42. He stated the purpose of EBP was to help prevent the spread of MDRO's. He stated nursing administration was responsible to ensure staff were following proper EBP protocol, including utilizing PPE. The DON stated all staff were trained on EBP through in-services conducted at the facility. He stated a potential negative outcome for failure to follow EBP protocol was the spread of infection. Record review of the facility sign posted outside Resident #42's door, titled Enhanced Barrier Precautions, undated, revealed: Everyone must:Clean their hands, including before entering and when leaving room. Providers and staff must also:Wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use:central line, urinary catheter, feeding tube, tracheostomyWound Care; any skin opening requiring a dressing Record review of the facility's policy titled Enhanced Barrier Precautions, dated August 2022, revealed: Policy Statement Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used an as infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:.g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh. wound care (any skin opening requiring a dressing).

Based on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications to meet the needs of the residents and establishes a system of records of receipt and disposition of all drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident reviewed for pharmaceutical services in that: The facility failed to have a system in place to ensure proper reconciliation of medications that would prevent missing medications for Resident #1. This failure could place residents at risk of having their medications diverted and/or receiving the incorrect dosage because due to staff not counting mediations in the narcotics refrigerator.Findings included: Record review of Resident #1's face sheet dated 03/30/2026, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: Unspecified diastolic (congestive) heart failure (heart's left ventricle becomes stiff, impairing its ability to fill properly, while still maintaining normal pumping function), acute respiratory failure, acute kidney failure, and generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #1's orders, dated 03/30/2026, revealed an order for Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) (benzodiazepine, used primarily for the management of anxiety disorders and for short-term relief of anxiety symptoms), give 0.25 ml by mouth every 4 hours as needed for anxiety. Start date 03/18/2026. Record review of Resident #1's Medication Administration Record dated 03/31/2026, revealed an order for Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) as needed for anxiety with a start date of 03/18/2026. The MAR further revealed Resident #1 was not administered Lorazepam from 03/18/2026 to 03/31/2026. Record review of the pharmacy shipment summary for Resident #1, dated 03/18/2026, revealed the facility received an order on 03/18/2026 for Lorazepam Oral Concentrate 2 MG/ML (Lorazepam), with a quantity of 30 ML. During an interview on 03/30/2026 at 9:30 AM, the ADM stated he was notified on03/24/2026, after an audit of the narcotic medications in the facility, a bottle of Lorazepam Oral Concentrate 2 MG/ML belonging to Resident #1 was missing. The ADM stated the audit was conducted by the DON and nursing staff. The ADM stated the prescription box for the Lorazepam was present in the narcotics refrigerator, but the bottle of medication was missing out of the box. The ADM stated there were seven nurses who had access to the narcotics refrigerator, and the seven nurses were suspended, pending an internal investigation. The ADM stated the seven nurses were sent for drug testing at the request of the facility. The ADM stated, to his knowledge, Resident #1 was never administered the medication, Lorazepam Oral Concentrate 2 MG/ML, as it was a medication prescribed as needed and Resident #1 did not request or have a need for the medication after the date the medication was received, 03/18/2026. The ADM stated this was a new medication ordered for the resident. The ADM stated the facility replaced the bottle of Lorazepam Oral Concentrate 2 MG/ML immediately, at the facility's expense, for Resident #1, and Resident #1 did not miss a dose of the medication. The ADM stated all seven nurses received disciplinary action for failing to count narcotics in the narcotics refrigerator. During an interview on 03/30/2026 at 11:00 AM, the DON stated during an audit of the narcotics held in the facility, LVN D found a prescription box of Lorazepam Oral Concentrate 2 MG/ML for Resident #1, but the bottle of medication was not in the box. The DON stated the medication was received on 03/18/2026 for Resident #1 to be administered as needed for anxiety. The DON stated the medication was stored in a secured and locked narcotics refrigerator that was locked in the medication storage room. The DON stated Resident #1 never received a dose of the medication as Resident #1 did not request the medication, and there was not a need for the medication at that time. The DON stated Resident #1 did not miss any doses of the medication, and the medication was replaced at the expense of the facility. The DON stated there were seven nurses who had access to the narcotics refrigerator. The DON stated each nurse held a key, during their shift, to the narcotics refrigerator. The DON stated these keys were passed to their replacement nurse during shift change, so both day and night shift nurses had access to the narcotic's refrigerator. The DON stated, upon internal investigation, it was determined the nursing staff were not counting the narcotic refrigerator, as required. The DON stated a full audit was conducted of all medication carts and medication storage, and this was the only medication found to be missing. The DON stated the missing medication for Resident #1, Lorazepam Oral Concentrate 2 MG/ML, was a PRN narcotic that was a new order for the resident. During an interview on 03/31/2026 at 9:00 AM Resident #1 stated he never took Lorazepam Oral Concentrate 2 MG/ML as needed or on a daily basis. Resident #1 stated it was not medication he needed. Resident #1 stated he did not know when the medication was prescribed to him. Resident #1 stated he has not felt like he needed the medication. The interview was ended due to Resident #1 no longer responding to questions. Resident #1 was asked if he wanted to speak to the surveyor at a later time and he mouthed his response, no and shook his head, no. During an observation on 03/31/2026 at 1:00 PM the narcotics refrigerator was observed in the medication storage room. The narcotics refrigerator was observed to be locked. The DON opened the narcotics refrigerator. A sealed bottle of Lorazepam Oral Concentrate 2 MG/ML was observed in a prescription box for Resident #1.The issue date on the prescription label showed 03/26/2026. During an interview on 03/31/2026 at 1:57 PM, LVN A stated she worked day shifts at the facility. LVN A stated upon arriving at the facility, a count was completed of all narcotics on her assigned nursing station with the nurse who was leaving for the day. LVN A stated a count was completed at the end of each shift as well with the oncoming nurse. LVN A stated only the nurses on each shift had access to PRN narcotics. LVN A stated the nurse working the floor was given a key for the narcotic refrigerator. LVN A stated CMAs and CNAs did not have access to PRN narcotics. LVN A stated PRN Lorazepam Oral Concentrate 2 MG/ML would have been kept in the narcotic refrigerator, located in the medication storage room. LVN A stated only nurses had access to the narcotic refrigerator. LVN A stated she did not recall counting Resident #1's Lorazepam Oral Concentrate 2 MG/ML because she was not counting the narcotic refrigerator during each shift. LVN A stated she did not have a reason for not counting the narcotic refrigerator at the beginning or end of each shift. LVN A stated she may have glanced at the medications in the narcotic refrigerator and may have seen the box, but she never picked it up to count it. LVN A stated she assumed based on the medication sheet that the bottle of Lorazepam Oral Concentrate 2 MG/ML was full since the count sheet showed it was full and never used. LVN A stated Resident #1 never asked for Lorazepam Oral Concentrate 2 MG/ML and she never administered it to him. LVN A stated it was a new medication order for Resident #1 and was only administered as needed. LVN A stated to count liquid medications she would hold a light under the bottle to measure the liquid accurately with the markings shown on the bottle to ensure it was counted accurately. LVN A stated she never picked up the bottle of Lorazepam Oral Concentrate 2 MG/ML to measure it because the count sheet showed it was full. LVN A stated she was not aware the bottle of Lorazepam Oral Concentrate 2 MG/ML belonging to Resident #1 was missing or that the prescription box was empty. LVN A stated she received training when she became a nurse on medication reconciliation and counting narcotics as well as ongoing training she received at the facility. LVN A stated it was important for a full count of narcotics to be completed each time the narcotic keys were exchanged to ensure medications did not become missing. LVN A stated if medications became missing a resident may miss a dose of medications that were needed. During an interview on 03/31/2026 at 2:25 PM, LVN B stated she worked day shifts at the facility. LVN B stated when she first arrived at the facility for her shift she would receive report from the exiting nurse and they completed a narcotic count of the medication cart together before the exiting nurse exchanged her keys to the medication cart and PRN narcotics. LVN B stated only nurses had access to the medication cart that contained PRN narcotics or the narcotic refrigerator. LVN B stated CMAs and CNAs did not have access to any PRN narcotics as PRN narcotics were only administered by a nurse. LVN B stated she was not aware Resident #1's Lorazepam Oral Concentrate 2 MG/ML was missing until she was notified by her ADM. LVN B stated she made sure to count the narcotic refrigerator now, when coming on for her shift and any time the keys were exchanged during her shift, for breaks or lunches, as well as at the end of her shift. LVN B stated this was not being done regularly, prior to the medication being missing,, as she trusted her coworkers and did not think someone would take the medication before. LVN B stated narcotic counts were documented on a count sheet when keys were exchanged between nurses. LVN B stated the count sheet did not previously include the narcotic refrigerator but had a count for all medication bottles combined. LVN B stated the count sheet was updated to include the narcotic refrigerator to be accounted for separately. LVN B stated she received ongoing training on counting narcotics and medication reconciliation. LVN B stated all nurses working the floor shifts were responsible for counting narcotics at the beginning and end of each shift with he oncoming or exiting nurse. LVN B stated she was aware she should have counted the narcotic refrigerator in her previous counts. LVN B stated she was not counting the narcotic refrigerator prior to the medication becoming missing. LVN B stated Resident #1 never requested the PRN Lorazepam Oral Concentrate 2 MG/ML, and she never administered the medication to him. LVN B stated, to her knowledge, Resident #1 never missed a dose of the medication due to it being missing. LVN B stated it was important to ensure narcotic counts were being completed to ensure medications didnt come up missing or residents did not miss medications. During an interview on 03/31/2026 at 2:47 PM, LVN C stated she worked day shifts at the facility. LVN C stated upon arriving for her shift, she counted medication carts with the exiting nurse or medication aide. LVN C stated this included counting all narcotics in the carts as well as in the narcotic refrigerator. LVN C stated she always counted all narcotic refrigerators and she never saw an empty box of Lorazepam Oral Concentrate 2 MG/ML belonging to Resident #1. LVN C stated she always picked up all bottles in the narcotic refrigerator to count them, and she never saw an empty box of medication or a missing bottle. LVN C stated only the nurse working the floor had access to the keys for the medication carts containing PRN narcotics or the narcotic refrigerator. LVN C stated all nurses working the floor shifts were responsible for counting narcotics at the beginning and end of each shift with he oncoming or exiting nurse. LVN C stated she had never administered Lorazepam Oral Concentrate 2 MG/ML to Resident #1, and Resident #1 never requested this medication. LVN C stated she did not believe the medication was needed at the time and the order was to be administered as needed. LVN C stated she received training on medication administration/reconciliation and counting narcotics through her nursing training as well as when she was hired at the facility. LVN C stated it was important to count all narcotics at the beginning and end of each shift to ensure residents' medications did not become missing. During an interview on 03/31/2026 at 3:08 PM, LVN D stated she completed an audit of the narcotics in the facility with the DON on 03/24/2026. LVN D stated when she took everything out of the narcotic refrigerator she found an empty box of Lorazepam Oral Concentrate 2 MG/ML belonging to Resident #1. LVN D stated the box contained the prescription information for the medication for Resident #1, but the box did not contain the bottle of liquid Lorazepam Oral Concentrate 2 MG/ML. LVN D stated she immediately informed the DON of the empty box and a full search for the medication was completed. LVN D stated the medication was not found. LVN D stated she only worked shifts as a floor nurse as needed by the facility, as her typical job duties were wound care. LVN D stated she did not work a floor nurse shift during the dates of 03/18/2026 - 03/24/2026. LVN D stated when she worked floor shifts, she always counted all narcotics with the oncoming of exiting nurse working the floor, LVN D stated only floor shift nurses had access to the PRN narcotics. LVN D stated the missing medication for Resident #1, Lorazepam Oral Concentrate 2 MG/ML, was a PRN narcotic and was a new order received for the resident. LVN D stated she was not aware of the empty box of Lorazepam Oral Concentrate 2 MG/ML for Resident #1 prior to 03/24/2026. LVN D stated Resident #1 never requested for this medication to be administered while she was working with him, and she never administered it to him. LVN D stated she did not believe Resident #1 missed a dose of the medication due to the medicine being missing. LVN D stated all nurses working a floor shift were responsible for counting PRN narcotics at the beginning and end of each shift with the oncoming or exiting nurse. LVN D stated it was important for all narcotics to be counted by two staff to ensure counts were accurate and to ensure residents did not miss any medications due to medicine coming up missing. LVN D stated she received training on medication administration/reconciliation and counting narcotics, regularly, at the facility. During an interview on 03/31/2026 at 3:30 PM, LVN E stated she worked day shifts at the facility. LVN E stated at the beginning of each shift she counted all PRN narcotics on the nurse's medication cart with the exiting nurse. LVN E stated she also counted again at the end of her shift with the oncoming nurse. LVN E stated all narcotics were always accounted for during her shifts. LVN E stated all floor shift nurses were responsible for counting the PRN narcotics at the beginning and end of each shift with he oncoming or exiting nurse to ensure all medications were accounted for. LVN E stated she became aware of the missing Lorazepam Oral Concentrate 2 MG/ML for Resident #1 when the ADM notified her of the missing medication. LVN E stated she never saw an empty box of Lorazepam Oral Concentrate 2 MG/ML for Resident #1. LVN E stated when she completed her PRN narcotic counts she only counted the PRN narcotics on the nurse's medication cart. LVN E stated she never counted the narcotics in the narcotic refrigerator in the medication storage room. LVN E was unable to provide a reason for not counting the narcotic refrigerator. LVN E stated Resident #1 did not ask for the PRN Lorazepam Oral Concentrate 2 MG/ML, and she never administered it to him, as there was not a need for it at that time. LVN E stated she received training on medication administration/reconciliation, as well as counting narcotics, while working at the facility. LVN E stated she now planned to count all medications including the narcotic refrigerator at the beginning and end of each shift to ensure accuracy. LVN E stated if narcotic counts were not completed at each shift change, medications could be taken and residents could miss dosages. LVN E stated, to her knowledge, Resident #1 never missed a dosage of Lorazepam Oral Concentrate 2 MG/ML due to the medication being missing. During an interview on 03/31/2026 at 4:50 PM, CMA stated she worked day shifts at the facility. CMA stated she was responsible for administering medications to residents that were scheduled medications. CMA stated she did not administer any PRN narcotic medications, as this was the responsibility of the floor shift nurse. CMA stated she did not have access to the narcotic refrigerator, as only the floor shift nurse had keys to it. CMA stated Resident #1 never requested for his PRN Lorazepam Oral Concentrate 2 MG/ML to be administered to him while she was working with him. CMA stated she had received training on medication administration/reconciliation and counting narcotics, while working at the facility. During an interview on 03/31/2026 at 5:38 PM the DON stated previously all PRN narcotics were supposed to be counted and documented on a count sheet that was supposed to be signed by the oncoming and exiting nurse. The DON stated there were no count sheets found for the date range of 03/18/2026 - 03/24/2026. The DON stated he was not aware these count sheets were not being done. The DON stated that the last full audit he completed on narcotics was in January 2026, and there were no concerns of missing narcotics at that time. The DON stated all of the facility's nursing staff received an in-service training on 03/26/2026 on counting narcotics,. The DON stated it was his expectation that all floor shift nurses count all PRN narcotics any time their medication keys were exchanged. The DON stated this included all breaks, lunches, and shift changes. The DON stated if a nurse left the building and had to hand over their keys to a nursing staff, his expectation was that the PRN narcotics were counted prior to the keys being handed over. The DON stated he believed the narcotic refrigerator was not being counted as it should have been. The DON stated all nursing staff were aware prior that the narcotic refrigerator contained PRN narcotics and should have been counted. The DON stated there was no specific system in place prior to ensure the refrigerator was counted. The DON stated the count sheets have since been updated to include the narcotic refrigerator and to specify how many bottles of refrigerated narcotics were present. The DON stated all nursing staff were responsible for counting PRN narcotics when they worked a floor shift, and there was no excuse for them not doing so. The DON stated it was his expectation that all count sheets were completed at each shift change and any time the medication keys were exchanged. The DON stated he planned to check the count sheets daily and planned to complete audits on all narcotics twice a week going forward. The DON stated if all narcotics were not counted properly, a resident could go without a needed medication if it became missing. During an interview on 03/31/2026 at 5:38 PM the ADM stated it was the responsibility of all floor shift nurses to ensure PRN narcotics were counted any time their medication keys were exchanged. The ADM stated he did not feel this was being done on each shift previously. The ADM stated the new process was for the oncoming and exiting nurse to document their count on count sheets that would be verified daily by the ADM and/or DON. The ADM stated the new count sheets included the narcotic refrigerator and how many specific bottles of narcotics were in the refrigerator, as well as any other narcotics in the refrigerator or on the medication carts. The ADM stated these counts were supposed to be documented previously, but the count sheets were not as specific. The ADM stated he did not know if where the count sheets were form 03/18/2026 - 03/24/2026 or if they were being completed. The ADM stated it was his expectation that these count sheets were completed at each shift going forward. The ADM stated he was not aware the narcotic medication refrigerator was not being counted at each shift prior to Resident #1's PRN Lorazepam Oral Concentrate 2 MG/ML becoming missing. The ADM stated all nursing staff were trained on medication administration/reconciliation and counting narcotics prior to the medication being missing, and they have since received an in-service training to ensure all nursing staff were re-educated on counting medications. The ADM stated it was important to ensure all narcotics were counted at each shift to prevent medications from being taken which could lead to a resident missing a scheduled or needed dose of medication. Record Review of the facility document titled, Narcotic Book/EMAR. Verification Sheet, undated, revealed the following: Record Review of the facility policy titled, Controlled Substances, dated April 2019 revealed the following: Policy Statement:The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation:4. Access to controlled medications remains locked at all times and access is recorded.8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.12. At the End of Each Shift:a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.c. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the administrator. Record Review of the facility document titled, Narcotic Book/EMAR. Verification Sheet, undated, revealed the following: AT SHIFT CHANGE, BOTH NURSES WILL VERIFY THAT ALL SCHEDULED AND PRN NARCOTICS ARE RECORDED IN THE EMAR AS WELL AS THE NARCOTIC COUNT SHEET DOCUMENT THE ACTUAL NUMBER OF CARDS, BOTTLES AND PATCHES THIS FORM AND ANY EMPTY CARDS I BOTTLES WILL BE TURNED IN TO THE DIRECTOR OF NURSING***EVERY SHIFT CHANGE WITHOUT EXCEPTIONS***(Failure to do so will result in automatic disciplinary action)Date:Time:Number of Narcotics Charted in Narcotic Book during shiftNumber of Narcotics Charted in EMAR during shift CART: Cards Bottles Patches FRIDGE: BottlesOncoming Nurse Outgoing Nurse

Based on observations, interviews, and record review, the facility failed to ensure each resident's bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff area for 1 of 5 residents (Resident #2 ) reviewed for resident call system.The facility failed to ensure Resident #2's call light was within reach while he was positioned in his bed.This failure could place residents at risk of not being able to call for assistance in emergency situations, a delay in care and services, and increased risk of falls and/or injuries. Findings include: Record Review of Resident #2's face sheet, dated 3/30/2026, revealed an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses that included: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of cognitive functioning, thinking, remembering, and reasoning), and Parkinson's disease with dyskinesia without mention of fluctuations (progressive neurological disorder that primarily affects movement).Record review of Resident #2's Annual MDS assessment, dated 04/30/2025, revealed under Section C, Cognitive Patterns, a BIMS score of 14 indicating the resident was cognitively intact. Record Review of Resident #2's Care Plan dated 01/16/2026, revealed the following focus areas: (Resident #2) has an ADL self-care performance deficit d/t muscle weakness r/t Parkinsons. The intervention area revealed the following: TRANSFER: (Resident #2) requires assistance by 1-2 staff for transfers . Focus area: (Resident #2) is High risk for falls r/t Gait/balance problems, Psychoactive drug use. The intervention area revealed the following: Be sure (Resident #2's) call light is within reach and encourage (Resident #2) to use it for assistance as needed. (Resident #2) needs prompt response to all requests for assistance. Record Review of Resident #2s's physician orders dated 03/30/2026 revealed the following diagnoses: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Parkinson's disease with dyskinesia without mention of fluctuations.During an observation and interviews on 03/30/2026 at 1:55 PM Resident #2 was lying in bed upon entering the room. While interviewing Resident #2, he stated he had never had a call light in his room. An observation of Resident #2's room confirmed there was no call light within reach of Resident #2's bed. The call light was found with the cord wrapped and placed behind resident #2's roommate's nightstand, approximately 3 feet from Resident #2's bed. Resident #2 stated he did not know the call light was behind the roommate's nightstand. Resident #2's roommate stated Resident #2 never had a call light, and if Resident #2 needed staff, he would press his call light so staff would respond. Resident #2's roommate then pressed his call light to alert staff they were needed. LVN E entered Resident #2's room in response to the call light. LVN E stated she did not know why Resident #2 did not have a call light within reach. LVN E located Resident #2's call light and unwrapped the cord. LVN E placed the call light within Resident #2's reach. LVN E tested the call light for Resident #2, and it worked. LVN E stated Resident #2's call light should have been within reach while he was in his bed. During an interview on 03/31/2026 at 10:35 AM the DOR stated Resident #2 did not have many physical limitations, but Resident #2 used a wheelchair. DOR stated Resident # 2 was able to transfer to and from the wheelchair on his own. The DOR stated he should have assistance with one staff to prevent falls from occurring. The DOR stated Resident #2 had the cognitive ability to use his call light. The DOR stated Resident #2 did not usually use his call light to request assistance, but he usually looked outside of his room for staff when he needed assistance. The DOR stated Resident #2's call light should always be within reach while he was in his room to prevent falls and to allow the resident to call for assistance if needed. The DOR stated all staff were responsible for ensuring call lights were within reach, and any staff could ensure a resident's call light was placed within their reach. During an interview on 03/31/2026 at 2:00 PM LVN A stated Resident #2 was capable of using his call light on most days, if needed. LVN A stated Resident #2 did not usually use his call light because he did not like to use it. LVN A stated Resident #2 usually came out of his room to get staff if he needed assistance. LVN A stated she could not remember a time Resident #2 used his call light on the previous day, 03/30/2026. LVN A stated Resident #2's call light should always be within reach when he was in his room to give the resident the opportunity to use the call light if necessary. LVN A stated she was not aware Resident #2's call light was wrapped and stored behind a nightstand. LVN A stated she never saw the call light or where it was placed, that she could remember. LVN A stated all staff were responsible for ensuring call lights were within a resident's reach to prevent falls. LVN A stated she received regular in-service training in regard to call lights. During an interview on 03/31/2026 at 3:10 PM LVN D stated Resident #2 was independent and was able to get in and out of his wheelchair on his own. LVN D stated Resident #2 did not press his call light often LVN D stated Resident #2 was capable of using his call light, but he was forgetful often. LVN D stated it was important for Resident #2 to have a call light within reach while positioned in bed, even if he did not use it, so he had the opportunity to use it, if needed. LVN D stated she had never seen Resident #2's call light wrapped behind a nightstand in his room. LVN D stated all facility staff were responsible for ensuring residents' call lights were within reach, and any staff could have placed Resident #2's call light within his reach for his safety. LVN D stated she received regular in-service training in regard to call lights. During an interview on 03/31/2026 at 3:30 PM LVN E stated Resident #2 was capable of using his call light when needed. LVN E stated she was not aware Resident #2's call light was not within his reach prior to her being notified on 03/30/2026. LVN E stated Resident #2's call light should have been within his reach for his safety and to prevent falls. LVN E stated she has received regular in-service training pertaining to call lights and ensuring all call lights were within a resident's reach while they were in their room. During an interview on 03/31/2026 at 5:38 PM the DON stated Resident #2 was capable of using his call light. The DON stated resident #2's call light should always be within reach when he was in his room. The DON stated he was not aware Resident #2's call light was wrapped and placed behind his roommate's nightstand. The DON stated it was important for all call lights to be within a resident's reach when they were in their room to prevent falls and for resident safety, even if the resident did not use the call light frequently. The DON stated it was the responsibility of all facility staff to ensure residents' call lights were within reach. The DON stated call lights should have been checked during all nursing rounds, every two hours, and anytime any staff entered a resident's room. The DON stated all staff received regular in-service training regarding call lights, and it was his expectation that all facility staff check resident's call lights throughout their shifts. During an interview on 03/31/2026 at 6:00 PM the ADM stated he was not aware that Resident #2's call light was not within his reach and was wrapped and placed behind his roommate's nightstand. The ADM stated all call lights should be within the residents' reach while they were in their rooms to allow the residents to use them when necessary. The ADM stated staff should check call lights within nursing rounds or when any staff enters or exits the resident's room. The ADM stated it was also his expectation that staff glanced into rooms as they walk down the hallways to ensure call lights were within the resident's reach. The ADM stated all facility staff were responsible for ensuring call lights were within reach. The ADM stated any staff member could place a call light within reach for the resident. The ADM stated all facility staff received regular in-service training pertaining to call lights. The ADM stated the administrative staff was responsible for overseeing staff and ensuring call lights were within reach. The ADM stated if a resident's call light were not within reach, the resident could miss out on getting care in emergency situations. Record review of the facility's document, Call System, Residents, dated September 2022, revealed the following: Policy Statement:Residents are provided with a means to call staff for assistance through a communication system that directly calls a s member or a centralized work station. Policy Interpretation and Implementation:Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/ bathing facilities and from the floor.The resident call system is routinely maintained and tested by the maintenance department.

Based on observation, interview, and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise, for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to implement interventions to ensure that Resident #1 did not have a significant weight loss of 16.8 pounds, a 10% body weight loss, between 12/03/2026 and 01/16/2026. This failure could place residents at risk for decreased nutritional status, malnutrition, and a decline in health.Record review of Resident #1's face sheet dated 02/04/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included: compression fracture of lumbar vertebra (fracture of a spinal bone in the lower back), Type 2 Diabetes Mellitus (a disease resulting in inadequate control of glucose in the blood), osteoporosis (a disease that weakens bones), and cognitive communication deficit (an impairment in communication effectiveness caused by decreased cognitive processes). Record review of Resident #1's admission MDS assessment, dated 12/09/25, reflected a BIMS score of 15, which indicated the resident's cognition was intact. Further review of MDS, Section D - Mood, indicated the resident did not have a poor appetite. Section GG - Functional Abilities - indicated Resident #1 completed the task of eating independently and required set up and clean up assistance prior to and following the activity. Section K - Swallowing/Nutritional Status, indicated the resident had an admission weight 158 pounds. Record review of Resident #1's Comprehensive Care Plan, initiated on 12/09/25 and revised on 01/13/26, reflected:Problem: [Name] Resident #1 has nutritional problem or potential nutritional problem (diabetes) watches her sugar intake by not eating sugary foods, like fruits, cakes, or cookies. On an LCS Regular diet with thin liquid consistency. Love Spanish foods, dislikes Chinese foods. At breakfast she prefers yogurt, milk, bacon and sausage, BMI 25.4.Goal: [Name] Resident #1 will maintain adequate nutritional status as evidenced by maintaining weight within (3) % of (145.8), no s/sx of malnutrition and consuming at least (75/100) % of at least (3) meals daily through the review date.Interventions:Provide and serve diet as ordered.Provide, serve diet as ordered. Monitor intake and record q meal.RD to evaluate and make diet change recommendations PRN. Record review of Resident #1's Physician's Orders dated 02/04/26 reflected the resident had a diet order for Regular diet, regular texture with thin consistency, for LCS. Further review reflected an order for Mirtazapine Tablet 7.5 MG by mouth at bedtime for appetite stimulant with a start date of 01/28/26. Record review of Resident #1's MAR for January - February 2026 reflected the resident was started on Mirtazapine 7.5 MG on 01/28/26 and had received daily doses since that date. Record review of Resident #1's weight record reflected the following weights:12/03/25 - 158.0 pounds01/04/26 - 145.8 pounds [-5.0% change, -12.2 Lbs.], [-7.7% change, -12.2 Lbs.]01/16/26 - 141.2 pounds [-7.5% change, -16.8 Lbs.], [-10% change, -16.8 Lbs.] Record review of Resident #1's admission nutritional assessment dated [DATE], completed by the DM, reflected the resident's admission weight was 158 pounds. Resident #1 was on an LCS Regular diet with thin liquids and an HS snack. Further review reflected the resident consumed meals independently in the resident room and had an oral intake of 50-75%. Interventions: continue current diet regimen prescription. Monitoring and Evaluation: monitor monthly weights, intake and follow up PRN. Record review of Resident #1's meal intake record for December 2025 and January 2026 reflected the resident consumed 51-100% of meals. The intake record reflected Resident #1 consumed 50% or less of a meal on the following dates: 12/18/25, 12/22/25, 12/31/25, 01/01/26, 01/02/26, 01/06/26, 01/10/26, 01/13/26, 01/20/26, 01/23/26, 01/24/26, and 01/28/26. During an observation and interview on 02/04/26 at 11:21 AM Resident #1 stated she was admitted to the facility on [DATE] from another nursing facility following a fall at home that resulted in a fracture in her lower back. The resident stated she was diabetic and had recently started insulin. Resident #1 stated she had lost over sixteen pounds since admission. The resident stated her weight loss was due to having to select foods on her tray that won't run my sugar up. The resident stated she was a picky eater and stated she did not care for some of the foods the facility served. Resident #1 stated she had been weighed once or twice a month since admission. The resident stated she did not recall whether or not she had seen a dietician since she admitted in early December. Resident #1 stated she brought her own protein shakes to the facility and was not offered liquid supplements at the facility. The resident stated she was getting a sandwich as a snack in the morning and in the evening and stated, I had to ask for those. Resident #1 stated she would like to meet with the DM for food choices and diet changes. The resident stated she had not spoken to the ADM or DON about her diet concerns. During an observation and interview on 02/04/26 at 12:37 PM, Resident #1 was served a lunch tray by the ADM. Observation of Resident #1's meal tray card reflected regular tray and consisted of a chicken sandwich on a bun with French fries, lettuce, tomato, mandarin oranges, and tea. Observed Resident #1 taste of the chicken sandwich and French fries. Resident #1 stated, the chicken could be warmer, and the fries are too salty. During an observation and interview on 02/04/26 at 1:10 PM, Resident #1 stated she ate most of her lunch. Observation of the tray revealed 75% of the food was consumed. The resident stated she ate all of the chicken and left a few pieces of the bun and stated she ate all of the mandarin oranges and left a few French fries. Resident #1 stated, It wasn't too bad. During an interview on 02/04/26 at 1:12 PM, CNA A stated she was responsible for passing the lunch trays. She stated Resident #1 had not complained to her about any of her meals since being admitted to the facility. CNA A stated Resident #1 usually consumed between 75-100% of her meals and was getting a sandwich in the morning and evening. CNA A stated if a resident complained of food, she would let the kitchen know and offer the resident an alternative. During an interview on 02/04/26 at 1:19 PM, LVN B stated the CNA's on day shift were responsible for getting resident weights each month. LVN B stated she thought the policy for newly admitted residents was to be weighed upon admission and monthly. She stated the CNA's turned in weights to the DON, who would then notify the physician of changes, if necessary. She stated Resident #1 had not complained to her about her meals and was receiving snacks twice daily. During an interview on 02/04/26 at 1:42 PM, the DON stated Resident #1 was admitted in early December and had a hospital stay of approximately one week shortly after admission. The DON confirmed Resident #1's admission weight of 158 pounds but stated he questioned the accuracy of that weight due to it being recorded as a standing weight and the other weights being recorded as a wheelchair weight. He stated the transportation aide was responsible for obtaining resident weights and she was out of the facility today to transport residents. The DON stated the transportation aide turned in weights to him to enter into the electronic health record, then he or the ADON would notify the physician of weight changes. He stated newly admitted residents were usually weighed upon admission, weekly for four weeks, then monthly. He stated he was unsure why Resident #1 was not weighed weekly upon admission but stated she had a hospital stay shortly after admitting to the facility, which may have contributed to the resident being missed on weekly weights. The DON stated the DM and RD would be notified if a resident had significant weight changes. He stated a care plan meeting was held for Resident #1 last week and the resident's weight loss was addressed, and an order was obtained from the physician for an appetite stimulant. The DON stated he was unsure why the significant change in Resident #1's weight was overlooked upon the weight change on 01/04/26. He stated he was unsure why the resident was not weighed upon readmission to the facility from the hospital in December. He stated he was unsure if the resident had weight loss in the hospital, but she should have been weighed upon readmission to the facility to determine if her weight had changed. During a phone interview on 02/04/26 at 3:20 PM, the RDN stated she had been servicing the nursing facility for 25 years. She stated her experience with newly admitted residents was that they were weighed weekly for the first month. She stated if a new admission had a weight change in the first month, the nursing facility would reach out to her for a virtual visit if it was between her on-site visits. She stated she had not been consulted by the facility regarding Resident #1's weight loss. The RDN stated she worked alongside the DM to monitor residents for changes and interventions if needed. She stated she had seen Resident #1 shortly after admission to the facility, but the resident had not shown any weight loss at that time. The RDN stated she did not have a note in the computer for the admission visit but stated her notes showed that the resident reported her usual weight was between 145-150 pounds. She stated the resident was on a regular diet for LCS, which meant the resident was served less sugary foods to avoid elevating her blood sugars. She stated she had seen the resident on 01/08/26 and noted some weight loss but felt that the resident's admission weight was inaccurate due to Resident #1's reporting of her normal weight of 145-150 pounds. She stated no recommendations were made at that time. The RDN stated she did not type a note in the electronic health record for the visit on 01/08/26. She stated she would change the diet order to a consistent carbohydrate diet today which meant the resident would be served a meal consisting of approximately 50 to 60 grams of carbohydrates and would provide more choices to the resident for her diabetic preferences. The RDN stated Resident #1 was on her list to be seen in the facility at her next visit, which was scheduled for 02/05/26. During an on-site interview on 02/04/26 at approximately 3:45 PM, the MD stated he was familiar with Resident #1 and had seen her weekly since admission. He stated he was made aware of Resident #1's weight loss last week after a care plan meeting. The MD stated he had written an order for the resident to have an appetite stimulant and would be seeing Resident #1 while he was at the facility today. He stated he would look for any additional recommendations by the RD and follow the resident's subsequent weight changes. During the follow up interview on 02/04/26 at 4:31 PM, the DON stated the facility policy for obtaining weights of newly admitted residents was that the resident was weighed upon admission and again the following day, upon readmission, and weekly for two weeks. The resident would then be changed to monthly or PRN for a significant weight change. He stated he was responsible for determining significant changes in weights and the electronic health record would notify of the significant change upon entering weights. The DON stated if a resident showed a significant change in weight the physician would be notified, and the facility would follow the policy for obtaining weights and implement any new orders. The DON stated he was not aware that resident #1's weight had changed as significantly as it had since admission. He stated he did not feel the admission weight for Resident #1 was accurate, but the resident's weight should have been weighed again and monitored according to policy to determine if there was actual weight loss. He stated the resident was receiving medication for appetite stimulation. The DON stated a potential negative outcome for failure to implement weight monitoring and timely interventions with significant weight changes was malnutrition, skin breakdown, and loss of independence. During an interview on 02/04/26 at 4:46 PM, the ADM stated he was not aware that Resident #1 had experienced significant weight loss until the care plan meeting last week when the appetite stimulant was added. He stated the ADM and DON are ultimately responsible for ensuring weights are monitored and notification of significant changes are made. He stated his expectation of staff regarding monitoring of weights was that residents were weighed on admission then weekly thereafter until a determination was made to go to monthly weights. The ADM stated a potential negative outcome for failure to implement weight monitoring and timely interventions with significant weight changes was that the resident could be hurt by not receiving the nutrients that they needed. Record review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, reflected the following: Policy StatementThe multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.Policy Interpretation and Implementation1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing.6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100].a. 1 month - 5% weight loss is significant: greater than 5% is severe.Interventions1. Interventions for undesirable weight loss shall be based on careful consideration of the following:a. Resident choice and preferences

Based on observation, interview, and record review, the facility failed to keep the resident's free of physical and chemical restraints that were not medically indicated for 1 of 15 residents (Resident #1) observed for physical restraints in that; The facility failed to ensure Resident #1 had a physician order, consent and evaluation for a chest restraint used for positioning and mobility. This failure could place residents at risk of injuries or entrapment. Findings include: Review of Resident #1's admission record, dated 10/09/25, revealed he was a 25 -year-old male admitted on [DATE] with the following diagnoses: spastic quadriplegic cerebral palsy (a type of cerebral palsy that affects all four limbs, causing stiffness, tightness, and difficulty with movement) and a history of falling. Review of Resident #1's quarterly MDS assessment, dated 08/29/25 revealed staff performed an assessment for mental status and Resident #1's cognitive skills for daily decision making were moderately impaired. The MDS further revealed Resident #1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with positioning, mobility and transfers. The MDS revealed Resident #1 did no use a trunk restraint, limb restraint, chair that prevents rising or other restraint in his chair. Record review of Resident #1's comprehensive care plan, undated, revealed he did not have a care plan for restraints or a care plan for the chest harness used. The care plan further revealed Resident #1 was totally dependent on staff for activities of daily living and transfers. Record review of Resident #1's order summary report dated 10/09/25 revealed no physician order for a chest harness or chest restraint. Record review Resident #1's medical record revealed no consent or completed evaluation of need for a chest harness or chest restraint. Record review of a facility document titled, Social Services Assessment for Resident #1, dated 06/17/25, revealed: Section B - Physical Functional Status:3. Are restraints currently being used with this resident?Answer - yes3b. If yes, describe type and reason for restraint use:Answer - [Resident #1] utilizes a stability device across his wheelchair to prevent slipping out of his chair. Observation on 10/09/25 at 10:33 AM revealed Resident #1 sitting up in his wheelchair in the TV area. Resident #1 was noted to have a specialized chair and a chest harness was noted across Resident #1's chest and strapped to the back of the chair. A buckle was noted on the chest harness and was currently buckled. During an interview on 10/09/25 at 4:20 PM, LVN A stated Resident #1 used the chest harness to help prevent him from falling. LVN A stated she did not think Resident #1 could remove the chest harness by himself. LVN A stated Resident #1 would be able to answer yes or no questions from the surveyor. During an observation and interview on 10/09/25 at 4:21 PM, Resident #1 was sitting in his wheelchair in front of the nurse's station by LVN A. Resident #1 was asked if staff put the chest harness on him daily and Resident #1 nodded yes. Resident #1 was asked if he could unbuckle the chest harness and Resident #1 shook his head no. During an interview on 10/09/25 at 4:23 PM, the ADM and the DON stated the chest harness on Resident #1 was used as a position changing device. The ADM stated the chest harness was made specifically for Resident #1's chair and it was his understanding that the chest harness was not a restraint. The ADM stated Resident #1 would fall if he did not have the chest harness due to Resident #1's spasticity (when muscles become abnormally stiff and tight, leading to involuntary muscle spasms, jerking, and difficulty with movement). Attempted phone interview on 10/09/25 at 5:20 PM with the physician for Resident #1 revealed no answer. During an interview on 10/09/25 at 5:25 PM, the DON stated all of the nursing staff were responsible for ensuring residents had a physician order for a position changing device. The DON stated he was ultimately responsible if a resident had a restraint. The DON stated Resident #1 did not have a restraint, he had a position changing device. The DON stated if a resident had any type of restraint, it would need a risk assessment, consent and physician order. The DON stated the residents would also need physician orders to check placement and the skin around the restraint. The DON stated Resident #1 would fall if the chest harness was not used for him. During an interview on 10/09/25 at 5:37 PM, the ADM stated he was ultimately responsible for ensuring residents had a physician order, consent and assessment for any restraint used. The ADM stated the facility did not consider the chest harness for Resident #1 to be a restraint. The ADM stated Resident #1 used the chest harness as a position changing device. The ADM stated a potential negative outcome to the residents if they did not have a physician order for a restraint was a risk of being physically harmed because it was a device. Record review of the facility's policy titled, Use of Restraints with a revised date of April 2017, reflected the following: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation:1. Physical Restraints are defined as any manual method or physical mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition , and this restricts his/her typical ability to change position or place, that device is considered a restraint.9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:a. The specific reason for the restraint (as it relates to the resident's medical symptoms);b. How the restraint will be used to benefit the resident's medical symptom; andc. The type of restraint, and period of time for the use of the restraint.

Based on, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 5 residents (Residents #1) reviewed for accident hazards, in that:. CNA A failed to adhere verbal redirection from staff, verbal yelling from Resident #1 and failed to check resident position in her wheelchair causing her to fall out of her wheelchair sustaining 2 lacerations, one to the head and one to the neck and being transported to the local emergency department. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 01/17/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling). Record review of Resident #1's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section GG 120. Mobility Devices C. Wheelchair Record review of Resident #1's care plane revealed the following: 08/21/2020 Problem: Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand. Intervention: Anticipate and meet Resident #1 needs Review past falls and attempt to determine cause of the falls. Record review of the facility incident report from 11/1/23 to 1/16/24 revealed the following: Resident #1 had a witnessed fall on 12/26/23 Record review of Resident #1 progress notes revealed the following: 12/26/23 9:55 AM Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C Record review of Form 3613 dated and signed 01/04/24 reveled that on 12/26/24 CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. Record review of CNA A's witness statement, dated 12/26/23, stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. Review of CNA B's witness statement, dated 12/26/23, stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. Record review of hospital records dated 12/26/23 revealed the following: Admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck. Physical Exam Constitutional: She is in acute distress Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound. Neck: Patient is in a c-collar(Neck Brace) Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed. During a confidential interview, it was stated that they were standing in the doorway with another staff member. They observed CNA A go retrieve Resident #1. When CNA A and Resident #1 passed by, Resident #1 screamed, and CNA B yelled to CNA A, CNA A, her feet!. They stated they heard a noise, and they looked out, and Resident #1 was on her face. During a Confidential Interview, it was stated that they heard CNA B yell stop. Before that, they heard Resident #1 yelling. They said Resident #1 yells, but this particular day (12/26/23), The yell was elongated. It was abnormal. After that, we heard the fall. During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. During a confidential interview, they stated they were present the day Resident #1 fell . They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling and getting closer. They said as they looked towards the entry of the dining room that was when she could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. During a confidential interview, they stated they were working with Resident #1 on the day that she fell . She said she was present on the day of the fall and saw everything. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. They stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him (CNA A) to stop, and CNA A kept pushing her. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They stated they observed CNA A keep pushing even after CNA B said to stop. During a confidential interview, they stated they were pulled to the floor to help the staff because another staff member was sick. They said it was near mealtime. They stated they observed Resident #1 yelling. She stated she observed Resident #1 feet under the chair. They stated they told CNA A that Resident #1's feet were under the chair and that he was dragging Resident #1's feet. They said they told CNA A that was why Resident #1 was yelling. They stated that the Activity Director called them, and when CNA A passed the door, they again told CNA that they were still dragging Resident #1 feet. They stated shortly after that moment, they heard the fall. They said when they told CNA A, he never readjusted her, checked her (Resident #1) feet, or even responded to them. They stated he kept pushing her. During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell . They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. During an interview on 01/17/24 at 1:34 PM, the DON stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #1 fell . She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing. During an interview on 01/17/24 at 2:05 PM, the ADM stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell . She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated she did not know who yelled. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she was unaware if CNA A had any hearing problems. During an interview on 01/18/24 at 2:38 PM at 2:52 PM, CNA A stated he did not mean for Resident #1 to fall. He stated he did not know her feet were under the wheelchair. He stated he did not feel a difference in pushing her. He said he did not hear anyone tell him to stop. He stated that he was the only CNA on the side where Resident #1 resided. He stated that he believed this was why he did not pay attention. He said he was worried about getting everyone out of the dining room by himself. He stated there was no other staff in the dining room with him. He stated there were other residents in the dining room. He stated the kitchen staff was in the kitchen. He said he was unaware that Resident #1 would put her feet down. He stated that she had large legs and had previously inquired about leg rest for another resident. He said he had not asked for leg rest for Resident #1. He stated he was told by housekeeping staff that maintenance would get them. He said he brought this to maintenance attention and was told it would be taken care of. He stated he felt that he did not receive adequate training. He stated he was on the floor one day with another staff and that training did not include getting to know the other residents but instead included asking him to help with the larger residents and telling him to change people on his own. He was never informed that Resident #1 would drop her feet. He stated if he had been trained about Resident #1, he would have checked her feet. He said he pushed her, and she fell out of the chair. He stated he only stopped because he saw her fall forward. He stated he never stopped until she started falling forward. Record review of a confidential witness statement revealed the following: They assisted in the assessment of Resident #1. During the course of providing care to Resident #1, they overheard the Activity director tell CNA A, We told you to stop pushing her; her legs were under her wheelchair. Record review of a confidential witness statement revealed the following: They heard Resident #1 screaming for at least 5 seconds. They stated they recognized her scream because when Resident #1 did not want to be moved, she would scream. They looked at another staff and then took a step where they could see out the door. They saw Resident #1 mid-fall. They stated Resident #1 hit her head first. They stated they heard CNA A say they were sorry several times. Record review of a confidential witness statement revealed the following: They stated the Tuesday after Christmas the heard Resident #1 shouting. It was for at least 5 seconds before they got up to check. They said it was normal for Resident #1 to shout, but not for long. They stated that as they were walking towards the door, that was when they heard the thud. Record review of a confidential witness statement revealed the following: They stated the day Resident #1 fell , CNA A pushed her even though she was yelling. They said they observed the ADM in the hallway. They stated if the ADM had asked what was going on, the fall may have been prevented. They stated they observed the ADM continue to walk until CNA A yelled, ' Ol Lord. Record review of the facility policy, Safety and Supervision of Residents (Revised 2017), revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The care team shall target interventions to reduce individual risk related to hazard in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risk and hazard shall include the following: Communicating specific interventions to all relevant staff assigning responsibility for carrying out interventions providing training is necessary. ensuring that interventions are implemented and documenting interventions Systems Approach to Safety Resident supervision is a core component of systems approach to safety. The type and frequency of the resident supervision is determined by the individual's residents assess needs and identified hazards in the environment. Resident Risks and Environmental Hazards Due to their complexity and scope, certain residents risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Falls Other topics related to resident risk and environmental hazards may be addressed within related policies and procedures.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 20 residents (Resident #15 and 23) with orders for psychotropic and/or antibiotic medications, in that: 1) The facility failed to have physician's orders, assessments, care plan, communication, and coordination of care with physician/pharmacist/staff/pain management physician in place for Resident #15 related to pain management. 2)The facility failed to ensure Resident #23 received physician ordered medications prescribed for anxiety and a UTI. An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. Additionally, these failures could place residents at risk for an increase in behaviors and infection symptoms. The findings include: Resident #15: Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle). Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days. Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days. Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23. Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023. Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8: 7/7/22 at 7:34 AM - 7 7/23/22 at 19:22 (7:22 PM) - 8 8/7/22 at 14:32 (2:23 PM) -6 8/23/22 at 8:59 AM - 6 8/30/22 at 22:49 (10:49 PM) - 8 9/2/22 at 6:58 AM - 7 1/13/23 at 3:58 AM - 6 Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following: Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 . Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give 1/2 hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 . Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus. Tylenol extra strength 500mg every 8 hours as needed for MS. Requip 0.25mg every day for Restless Leg Syndrome. Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms. Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10. Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention. Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump. Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities. Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed. Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication. Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following: Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations. Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN. Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations. Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18. Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following: Steps in the procedure: 8. Skin: A. Intactness. B. Moisture. C. Color. D. Texture. E. Presence of bruises, pressure, sores, redness, edema, rashes. 14. Pain: Pain: a. F. Current medication and treatments for pain. Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following: The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain. General guidelines: 1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: F. Identifying and using specific strategies for different levels and sources of pain. G. Monitoring for the effectiveness of interventions. Steps in the procedure: Assessing pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): A. History of pain and its treatment including pharmacological and non-pharmacological interventions. Implementing Pain Management Strategies: 3. The physician and staff will establish a treatment regimen based on consideration of the following: B. Current medication regimen. 4. Strategies that may be employed when establishing the medication regimen include: C. Combining long-acting medication with PRN's for breakthrough pain. 5. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following: Policy statement: Orders for medication and treatments will be consistent with principles of safe and effective order riding Policy, interpretation, and implementation: 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following: Policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care. Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following: Policy statement: The attending physician will be responsible for the following: 1. Excepting responsibility for initial and subsequent resident care. 2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards. Providing appropriate care: 9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions. On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested. The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following: Request to remove immediate jeopardy dated 1/12/2023 How corrective action will be accomplished for those residents affected by the violation: Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. Completion date 1/12/2023. LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. Completion 1/12/2023 In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care. Completion 1/12/ 2023 How the facility will identify other residents with the potential to be affected by the same violation: Only one resident in the facility has an internal pain pump currently. Completion 1/12/2023 What measures will be put into place or systematic changes made to ensure the violation will not reoccur. Admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information. Completion 1/12/2023. How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur. Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved. Completion 1/13/2023 Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023. Addendum to request to remove immediate Jeopardy dated 1/12/2023 Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff. Nursing staff was in-serviced included regarding the remote bolus PRN doses. In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows: Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's. Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management. Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders. Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs. During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan. Resident #23: Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psyc [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide pain management to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one (Resident #15) of 24 residents reviewed for pain management. The facility did not ensure Resident #15's implanted pain pump for pain was being used as prescribed by a physician. The facility was unaware Resident #15 had pain medication prescribed for the pain pump as needed up to three times a day. An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. Findings included: Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle). Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days. Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days. Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23. Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023. Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8: 7/7/22 at 7:34 AM - 7 7/23/22 at 19:22 (7:22 PM) - 8 8/7/22 at 14:32 (2:23 PM) -6 8/23/22 at 8:59 AM - 6 8/30/22 at 22:49 (10:49 PM) - 8 9/2/22 at 6:58 AM - 7 1/13/23 at 3:58 AM - 6 Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following: Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 . Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give 1/2 hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 . Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus. Tylenol extra strength 500mg every 8 hours as needed for MS. Requip 0.25mg every day for Restless Leg Syndrome. Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms. Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10. Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention. Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump. Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities. Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed. Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication. Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following: Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations. Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN. Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations. Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18. Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following: Steps in the procedure: 8. Skin: A. Intactness. B. Moisture. C. Color. D. Texture. E. Presence of bruises, pressure, sores, redness, edema, rashes. 14. Pain: Pain: a. F. Current medication and treatments for pain. Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following: The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain. General guidelines: 1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: F. Identifying and using specific strategies for different levels and sources of pain. G. Monitoring for the effectiveness of interventions. Steps in the procedure: Assessing pain: 1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): A. History of pain and its treatment including pharmacological and non-pharmacological interventions. Implementing Pain Management Strategies: 3. The physician and staff will establish a treatment regimen based on consideration of the following: B. Current medication regimen. 4. Strategies that may be employed when establishing the medication regimen include: C. Combining long-acting medication with PRN's for breakthrough pain. 5. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following: Policy statement: Orders for medication and treatments will be consistent with principles of safe and effective order riding Policy, interpretation, and implementation: 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis. Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following: Policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care. Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following: Policy statement: The attending physician will be responsible for the following: 1. Excepting responsibility for initial and subsequent resident care. 2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards. Providing appropriate care: 9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions. On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested. The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following: Request to remove immediate jeopardy dated 1/12/2023 How corrective action will be accomplished for those residents affected by the violation: Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. Completion date 1/12/2023. LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. Completion 1/12/2023 In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care. Completion 1/12/ 2023 How the facility will identify other residents with the potential to be affected by the same violation: Only one resident in the facility has an internal pain pump currently. Completion 1/12/2023 What measures will be put into place or systematic changes made to ensure the violation will not reoccur. Admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information. Completion 1/12/2023. How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur. Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved. Completion 1/13/2023 Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023. Addendum to request to remove immediate Jeopardy dated 1/12/2023 Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff. Nursing staff was in-serviced included regarding the remote bolus PRN doses. In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows: Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's. Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management. Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders. Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs. During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention program and control infections and communicable diseases for all residents, staff, volunteers and visitors for 6 of 52 residents (Resident #2, #5, #8, #16, #33, and #45) reviewed for infection control particularly COVID-19 as evidence by: The facility failed to: A. Failed limited number entrances into the facility ensuring staff to enter the facility without being screened; and to educated and informed staff of isolation protocol; B. Failed to protect residents form exposure from other COVID 19 positive residents; C. Failed to ensure PPE equipment was not worn correctly; D. Failed to ensure staff use infection control practices that would prevent cross-contamination by not washing hands or using hand sanitizer between residents' care; E. Failed to ensure all staff on the positive side (Hall 1) were wearing N95 mask; F. Failed to redirect residents who were COVID-19 negative from roaming halls without wearing mask correctly or not at all; G. Failed to train staff on how to clean rooms that COVID-19 positive residents were residing in; H. Failed to ensure staff who remained on designated hall and equipment was not cleaned or sanitized when going from positive and to negative sides; I. Failed to provide staff with yellow biohazard bags for soiled linen and red biohazard bags for PPE used during care for COVID-19 positive resident side (Hall 1). This failed practice affected 39 residents who tested positive for COVID-19 and 10 expired after testing positive and had the potential to affect all resident putting them at risk for COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern. Findings include: The surveyors entered on [DATE] due to a complaint intake # 1 received date [DATE] and priority date [DATE] with 15 residents positive for COVID-19. Observation and interview on [DATE] at 3:30 PM, surveyors walked up to front door and rang door bell. Surveyors observed Local Health Department notification on front door the facility was placed on quarantine order (locked down, doors must be locked) and restricted visitors from entering. Surveyor pulled on the door and it was unlocked allowing access the facility. CNA #8 appeared from the office not wearing a mask and stated she was on light duty and did not know who was taking temperatures. There were no sanitizing wipes at the front door. When asked why the door was unlocked, CNA #8 stated a resident's son had just left. Surveyors started walking toward the nurse's Hall when M.R staff hollered down the hall and told us to wait and she came with thermometer to take tempt in our ear. (it was not sanitized down between taking surveyors temperature). Interview on [DATE] at 3:30 PM, ADON #1 stated Hall 1 is COVID-19 positive side and Hall 2 is negative side. She continued state that residents that are positive and currently on Hall 2 are moving to Hall 1 (indicated as the positive COVID-19 side). And resident who are current negative on Hall 1 are being moved to Hall 2. Interview on [DATE] at 3:34 PM, ADON#1 stated all the housekeeping left at 3:00 PM, after positive resident had been moved to Hall 1 (positive side ) her nursing staff was going to clean the rooms in Hall 2 after positive residents were moved out of those rooms. She confirmed the staff was not trained to deep clean for isolation. Interview on [DATE] at 3:50 PM, Corporate RN stated health department notified her around 1:50 PM of results of an additional 20 more residents positive for COVID-19. She continued to state she did know how many of the positive residents had been moved to isolation hall for she having to answer phone calls and talk with the state and health department. Observed on [DATE] at 4:00 PM, Resident #15 (negative) without a mask was in dining room in his wheelchair at the dining room table while staff was moving residents that were positive for COVID-19. (he was seen roaming the halls throughout the day with no mask). Observations on [DATE] at 4:05 PM, revealed the foam hand sanitizer holders were empty in resident rooms. According to the CDC Coronavirus Disease 2019 (COVID - 19) guidelines for facilities found at www.cdc.gov/COVID19., they are to Put alcohol-based hand rub in every resident room, identify dedicated employees to care for COVID-19 patients and provide infection control training, wear facemasks, eye protection, post signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE, and gloves, available immediately outside of the resident room, and position a trash can near the exit inside any resident room to make it easier for employees to discard PPE. These guidelines were not being followed by the facility. Interview on [DATE] at 4:10 PM, #1 RN revealed the facility had moved 5 of the 20 positive COVID-19 residents to the isolation side (Hall 1); and had moved 2 residents who tested negative for to Hall 2. Per ADON, Nursing staff members were cleaning the rooms between the moves because the environmental housekeeping staff left at 3pm. Interview on [DATE] at 4:20 PM, ADON#1 stated resident #8, #30, and #33 test results had not returned. When asked, she confirmed each these residents would stay in a single room with no roommate until results came back. Interview on [DATE] at 4:30 PM, ADON #1 stated that Speech Therapist worked her shift today; the health department cleared her to go to work on [DATE]. She stated restorative CNA #6 was notified today she tested positive for COVID-19. She stated CNA #4 would be allowed to return to work tomorrow [DATE]; health department released her after a 7-day asymptomatic quarantine. Health Dept. stated her cough was [MEDICAL CONDITION] and not related to [MEDICAL CONDITION]. ADON stated CNA #3's doctor put her on 14-day quarantine which had to start over yesterday because her son came home from the hospital. She is on quarantine without doing testing because she has [MEDICAL CONDITION] cell; doctor doesn't want to put her at higher risk. Interview on [DATE] at 5:00 PM, Corp RN stated she pronounced Resident #2 expired at 4:20 PM (she was positive for COVID-19). Observed on [DATE] at 5:45 PM night staff entering the facility without being screened and passed negative area to clock in and to their work hall. Observation on [DATE] at 5:50 PM of shift change for the 6P to 6A shift, staff coming in the front door and back door. Which neither door entrance had a staff member to stop and screen (take temperature/questionnaire) any visitors/staff coming in or going out. Observed on [DATE] at 5:50 PM, on coming staff shifts would go the back tables outside of the dining room where paper grocery bags with the staff member's name written on the outside of the bag. Inside the paper grocery bag held the staff member's disposable PPE. Observed outgoing staff members returning their disposable PPE to same paper grocery bag with their name on it after their shift. Interview on [DATE] at 5:53 PM, Corp RN stated that staff re-use their disposable PPE, turning the disposable PPE dirty to dirty placing it back into paper bag for re-use for their next shift. RN stated she did not have enough disposable PPE for staff to have new disposable PPE daily. In an interview on [DATE] at 12:35 PM, CNA #1 stated he was told to reuse his gown and mask for 5 days. They are supposed to use the mask and gown unless they got dirty or torn. Observation of this CNA revealed him coming out of a resident's room and using hand sanitizer that he pulled out of his pocket. When asked, CNA #1 was asked where the staff put their used disposable PPE when they're through with it, he pulled out of his pocket and showed the surveyor a roll of clear bags (that are used in resident rooms on Hall 2). Both CNA #1 and CNA #2 stated that they did not have any red biohazard bags for contaminated disposable PPE on Hall 2. In an interview at the same time, CNA #2 also stated that they were told to use their mask and gown for five days unless they became soiled. Observed on [DATE] at 5:55 PM, CNA #7 came in through the back door without being screened and went to table outside dining room to put on her disposable PPE that is in paper sack and then she went to clock in. After she clocked in, she went straight to Hall 2 (negative side) to start her shift and was never screened. Observed on [DATE] at 6:30 PM, CNA #7 spraying sanitizer down the rails in the hallway on Hall 2. Record reviewed on [DATE] at 6:40 PM, screening notebook to review those who just clocked in for the night shift; CNA #7 had not been screened. RN #1 stated she did not have her checked that she was in the building. Interview on [DATE] at 6:00 PM, Corporate RN stated she does not have enough parking in the back for staff to park, so they come in the back and front entrance into the building. She stated they do not have enough staff to man doors. Observations made revealed the staff were able to access back door with a code thus being not screened. Observations on [DATE] at 6:04 PM made when onsite during survey revealed 1 car plus the required police car out in the front of the building. Staff would enter building (front or back door) and go to Hall 1 for temperature check. Observed on [DATE] at 6:05 PM meal cart went to the positive and back to kitchen through the negative side without being sanitizing. Interview on [DATE] at 6:09 PM, DS #1 stated they clean the carts including the wheels after every meal with spray down with a bleach combo. He stated the meal cart was not sanitized until it was returned to kitchen after being on the positive side and rolled backed through the negative side. Observed on [DATE] at 6:15 PM, LVN #7 came out of the isolation hall in which the entire hall was on isolation through the fire door with only a face mask on. (Note: staff is supposed to go through dirty to clean rooms with bathroom in between doff PPE in dirty room, wash hands in bathroom and exit through clean room) LVN #7 stated she not been informed by management the whole hall was now on isolation (she was just working at the end of the hall with 6 rooms on isolation with plastic sheet dividing the hall). Observed on [DATE] at 9:00 AM, surveyors walked to the door and rang doorbell, staff not available to screen at door. Corporate DON escorted surveyors to Hall 1 nurse's Hall to fill out the questionnaire and took surveyors' temperature. Interview on [DATE] at 9:00 AM, RN #1 stated Resident #45 was sent to the hospital at 7:00 AM for COVID-19 symptoms. She continued to state Resident #16 was declining, they cannot keep her O2 stats above 85% and she is on 4 liters of oxygen. RN #1 stated Resident #16 is COVID-19 positive and is a DNR and is not going to the hospital. Observed on [DATE] at 9:15 AM, Resident #15 (negative) was at Hall #2 with mask on but not covering his nose. Interview on [DATE] at 9:20 AM, HSK #1 regarding cleaning cart, she stated she was going to take cleaning cart to Hall 1 (positive side) to clean and when she finished would return back through negative side to park cleaning cart in the housekeeping close without cleaning the cleaning cart. Record review on [DATE] at 9:25 AM the resident roster with new room numbers and Resident #7 (negative ) was placed in Resident #8 (results pending) room. Interviewed ADON stated she was unaware of that and Resident #8 was not to have roommate. Observation on [DATE] at 10:50 AM revealed Resident #8 lying in her bed watching TV and stated she was very nauseated; when asked if she had a roommate, Resident #8 stated yes it was #7. Interview on [DATE] at 9:35 AM, HSK Super (contracted) stated she cleaned Hall 100 (positive side) last night and brought the cart back through fire doors (dividers for the 2 sides) and put in utility room where she cleaned the cart. She stated she had 3 staff for that day and laundry person called in. All her staff walked off the job and these are all new staff that she is still training. Observed on [DATE] at 10:30 AM, only LVN #2 on the positive side wearing N95 mask, 3 CNAs and 2 LVNs were not wearing N95 masks. Observation on [DATE] at 10:45 AM, revealed LVN #7, who was working the previous day ([DATE]) on the COVID-19 positive side; today ([DATE]) working on Hall 2 which is the negative COVID -19 side. Interview on [DATE] at 11:00 AM, ADON #1, stated LVN #7 was working Hall 2. When asked about keeping dedicated staff to the COVID-19 + side, once staff has worked on the COVID-19 positive side they are to stay on that side. The ADON #1 replied LVN #7 called her the previous evening at 9 PM crying, stating to her that she wasn't going to return to work, so she thought it would be better to move her over to Hall 2 rather than have her quit. Interview on [DATE] at 11:00 AM, HSK Supervisor stated she was going to take the big black cart to the positive side and leave it. Observed on [DATE] at 11:45 AM, staff coming in the back door by using a code not being screened. Interview on [DATE]at 12:05 PM, ADON stated she was just informed Resident #8 and Resident #33 are positive for COVID-19. (Note Resident #7 (negative)was put in the Resident #8's room the day before). Observed on [DATE] at 12:10 PM, Hall 2 (negative side) had no antimicrobial gel in resident's rooms. Observed on [DATE] at 12:41 PM, staff bringing dirty linens from the COVID-19 positive side to the negative side to take to the laundry room. Observed on [DATE] at 12:42 PM LVN #6 on the COVID-19 hall taking meal trays into resident rooms. She immediately came right back out and got another foam box and foam cup. She did not have time to wash her hands for 20 seconds. She wasn't in the room for 20 seconds. She was observed not sanitizing hands between resident rooms. Observed on [DATE] at 12:44 PM of COVID-19 wing (Hall 1) revealed CNA #5 delivering meal boxes to residents. She went in the room and came right back out, not having time to have washed her hands for 20 seconds. She was observed repeatedly taking trays into resident rooms and coming immediately back out of the rooms. She was not observed to use any hand sanitizer between the residents. Observed on [DATE] at 12:45 PM, staff was delivering meals and drinks to resident on the positive side and staff was not washing or using hand sanitizer between rooms. Observed on [DATE] at 12:47 PM, of the clean (negative) and dirty (positive) rooms where isolation staff are supposed to don and doff PPE revealed in the dirty (positive) room; red bag with dirty (positive) PPE sitting on a chair and on an over the bed table not in receptacle. LVN #2 stated she did not know where the red bag receptacle boxes were, she said she didn't work yesterday ([DATE]) when all the residents were moved. She stated when there were 4 rooms in the very back of the hall (original isolation hall) had red bag receptacles. She stated they hold the red biohazard bag with theirs to put the dirty disposable PPE in the red biohazard bag. Interview on [DATE] at 12:55 PM, ADON #1 stated that HSK #2 also came back positive. She stated they were going to retest Resident #7 because she was placed in a room with a roommate that was positive and retest Resident #30 because the lab said they did not have her sample. Interview on [DATE] at 3:30 PM, Interim Administrator #2 stated that her expectation was for staff to wear the PPE for one day and to change it out; she expected staff to wash hands in between resident meal trays on the isolation unit. Interim Administrator #2 was asked regarding the back door not having a lock on it and a code that staff put in and could walk right in without being screened. She stated that they would put staff members at the back door to screen the employees as they came in. Record reviewed positive COVID-19 residents' clinical records regarding admitted , age, [DIAGNOSES REDACTED]. RESIDENT #2 Record review of the face sheet for Resident #2 revealed was [AGE] years old and admitted [DATE] and readmitted [DATE] with the following Diagnoses: [REDACTED]. hemorrhage, unspecified, Malignant neoplasm of colon, Essential (primary) hypertension, and Dehydration. Resident #2 tested positive for COVID-19 on [DATE] and expired on [DATE] in the facility. RESIDENT #5 Record review of the face sheet for Resident #5 revealed was [AGE] years old and admitted [DATE] and readmitted [DATE] with the following Diagnoses: [REDACTED]. disturbance(Admission), [MEDICAL CONDITIONS], Acute and Chronic [MEDICAL CONDITION], Type 2 diabetes mellitus with unspecified diabetic retinopathy without [MEDICATION NAME], Type 2 diabetes mellitus with diabetic [MEDICAL CONDITIONS], Long term (current) use of insulin. Resident #5 tested positive for COVID-19 on [DATE]. RESIDENT #8 Record review of the face sheet for Resident #8 revealed was [AGE] years old and admitted [DATE] and readmitted [DATE] with the following Diagnoses: [REDACTED].>Acute and chronic [MEDICAL CONDITION], Encounter for observation for suspected exposure to other biological agents ruled out-covid-19 exposure, Influenza due to identified novel influenza [MEDICAL CONDITION] with other respiratory manifestations, Abdominal aortic aneurysm, without rupture, hypertension, I35.0Nonrheumatic aortic (valve) stenosis, I42.0 Dilated [DIAGNOSES REDACTED], Unspecified systolic (congestive) heart failure, Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, [MEDICAL CONDITION], Malignant neoplasm of unspecified part of left bronchus or lung, Type 2 diabetes mellitus, [MEDICAL CONDITION], [DIAGNOSES REDACTED]. Resident #8 tested positive for COVID-19 on [DATE]. RESIDENT #16 Record review of the face sheet for Resident #16 revealed was [AGE] years old and admitted [DATE] with the following Diagnoses: [REDACTED]. Resident #16 tested positive for COVID-19 on [DATE]. RESIDENT # 33 Record review of the face sheet for Resident #33 revealed was [AGE] years old and admitted [DATE] and readmitted [DATE] with the following Diagnoses: [REDACTED].>Hypertension, Shortness of breath, Anorexia, [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION], Urinary tract infection, Type 2 diabetes mellitus without complications. Resident #33 tested positive for COVID-19 on [DATE]. RESIDENT #45 Record review of the face sheet for Resident #45 revealed was [AGE] years old and admitted [DATE] and readmitted [DATE] with the following Diagnoses: [REDACTED]. Heart failure, hypertension. Resident #45 tested positive for COVID-19 on [DATE] and admitted to the hospital on [DATE] with shortness of breath and low O2 stats and expired on [DATE]. Record reviewed facility policies: Infection Prevention and Control Policies and Procedures Biohazardous Waste or Regulated Medical Waste (RMW): Cost Effective, Safe Handling and Disposal dated [DATE] Policy: The facility will make responsible decisions regarding the handling and disposal of solid waste. Every facility will be in compliance with federal, state, and local laws and regulations of the jurisdiction in which it is located. Each facility will use good judgement, be prudent, and be in compliance with regulations, and not discard ordinary solid waste with the biohazardous waste. Only solid waste categorized by regulation as biohazardous waste or regulated medical waste will be discarded in red bag or biohazardous trash. Policies and Procedures: Training: 1. Inform and train personnel responsible for disposal or handling of regulated medical waste on the proper handling and disposal procedures, including what constitutes medical waste and what is not to be disposed of in red bag trash. Training is a key factor. 2. In addition to Federal regulations, the OSHA Bloodborne Regulation requires annual training on its provisions, which include proper handling of biohazardous waste. Training can occur more frequently as needed. 5. Training is appropriate to the language and literacy level of the participant. 6. Document attendance noting: 7. Staff competency is ascertained through either written or observed methods. Housekeeping In-service Procedures for Infection Control dated [DATE] Purpose: Basic principles to be understood and implemented by Housekeeping and Laundry personnel. Procedures for Infection Control 1. Use an effective quaternary germicidal solution, along with systematic cleaning of all patient areas. 2. All surfaces must be exposed to the chemical agent. Anything short of actual contact will not do the job. 3. Always dilute chemicals properly - too little will be ineffective, too much will be wasteful. 4. Never use a chemical on any surface until you are sure it is safe for that purpose. 7. Change your water often. Failure to do so will result in cloudiness and sedimentation which will lessen the effectiveness of the germicide. 8. Schedule complete routine cleaning of closets and drawers to eliminate insect breeding grounds. 9. Follow all Standard Precaution procedures. 10. Schedule and hold regular in-service meetings. Executive Housekeeper should be an active member of Infection Control Committee. 11. Laundry and linen procedures must be designed to prevent cross infection. 12. Schedule and receive tests to detect any communicable diseases. Make available the [MEDICAL CONDITION] vaccine to all employees. 13. Use hand lotion. It is a good practice to use it after cleaning as disinfecting agents are still at work in your skin. 14. Wash hands regularly using the 9-Step Hand Washing technique. Housekeeping Job To Be Done: Contaminated Isolation Room Cleaning Steps to do Job Before entering the room: 1. Scrub hands and arms for 3 minutes with disinfectant soap. 2. Dress in isolation clothes: 1st: Booties, 2nd Cap, 3rd Mask, 4th Gown, 5th Gloves Enter the Isolation Room: 3. Pick up and place in an isolation bag all personal property left behind by the patient. 4. Remove all trash, paper towels, toilet tissue. place them in a trash liner. Place the trash liner inside a trash collection bag. (Double bag method). 5. Remove the cubicle curtains, drapes, bed linen, double bag them.bag in isolation and then place outside the room. 6. Spray trash containers inside and out. Dry and reline. 7. Spray high areas and wails and dry them. 8. Spray disinfect the bed mattress and the bed frame and springs. Dry it . the bed is electric disconnect it before spraying. 9. Spray the rest of the room. Dry 10. Disinfect the bathroom. Use the 7-step wash-room cleaning method. .fill dispenser .pull trash .sweep the floor .spray the mirror/sink area and dry .spray the toilet area and shower stall and dry .wet mop the floor 11. Wet mop the patient room. 12. Wipe down cleaning equipment on daily basis with disinfectant solution before removing it. 13. Remove isolation apparel in the room prior to leaving. 14. Replace drapes and cubicle curtains. Patient kit put into place. 15. See everything in its place. Report repairs to supervisor. Additional Information: Isolation is the separating of one or group of patients from the rest of the facility because they have some type of communicable illness. The purpose is to prevent the spread of this disease. Isolation cleaning - refer to the efforts made to keep all bacteria at a low level and within one designated area. Use the systematic routine while working. To protect the facility from the patient, every effort is made to keep the bacteria in the room. Read and follow the directions on the labels. The spray solution will disinfect immediately. Entire bathroom must be wiped. Wring out the mop frequently. Normal cleaning of patient room except worker must gown up. Cleaning equipment is kept in the isolation room. Or must disinfect it before removing it. Housekeeping In-service Procedures for Infection Control dated [DATE] Purpose: To provide Housekeeping and Laundry staff with basic information about infection control as it relates to their day-to-day jobs. 3. Air and Dust-Borne Particles Control the Spread of Bacteria through Air and Dust-Borne Particles: a. Regular disinfection of all areas, especially floors, is the key to controlling the spread of infection. b. Germicide solution in the proper concentration, changing the solution every ,[DATE] rooms, as well as good damp mopping technique, will prevent the spread of bacteria. Personal Protective Equipment: Infection Prevention and Control dated [DATE] and emailed [DATE]. Policy: Facility staff follow clinical practice standards in the selection, use, don and doff of personal protective equipment. Procedure: 1. Perform hand hygiene. 2. Prepare all equipment needed in the patient or resident room. 3. Prepare for entrance into the isolation room. Choice of barrier protection depends on the top of isolation and current recommendations. A. Apply again, being sure it covers all outer garments. Full sleeves down to wrist. Tie securely at neck and waste. B. Apply surgical or respiratory mask around mouth and nose top and fit testing may depend on top of isolation, availability and current recommendations. C. Apply eyewear or goggles snugly around face and eyes, when needed. D. Apply clean gloves. Bring gloves cuffs over edge of gown sleeves. 4. Enter patient or resident room. Arrange supplies and equipment. 5. Explain purpose of isolation and precautions. 6. Perform care and services according to patient or resident need in following establish policy and procedure. 7. Remove personal protection equipment (order of removal may vary depending on top of PPE used) prior to leaving the patient/resident room. PPE should be removed at doorway or entity in anteroom. A. Remove gloves. Removed one glove by grasping curve and pulling gloves inside out over hand. Hold removed glove in gloved hand. Slide fingers of ungloved hand under the remaining glove at wrist. Peel glove off of over first glove. Discard gloves in the proper container. B. Remove eyewear or goggles. Handle by headband or earpiece. Discard in proper container. C. Untie neck strings and untie back strings of gown. Allow gown to fall from shoulders, touch inside of gown only. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams, and fold inside out into a bundle, and discard. 8. Leave isolation room A. Perform hand hygiene. B. Remove mask. If the mask secure over the ears, remove elastic from ears, pull mask away from face. For a tie-on mask, untie bottom string and then top strings, pull mask away from face and drop into the trash receptacle. Do not touch the outer surface of the mask. C. Perform hand hygiene. Hand Hygiene/Handwashing dated [DATE] Policy: Proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicated. NOTE: Hand hygiene/handwashing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff. Procedures: 1 Hand hygiene/hand washing is done: Before: A. Before patient/resident contact. B. Before eating or handling food. C. Before starting work. D. Before smoking or eating. E. Before taking part in a medical or surgical procedure. After: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds. D. After toileting or assisting other with toileting, or after personal grooming. E. After smoking or eating. F. After coughing, sneezing, or blowing the nose. G. After handling uncooked animal products, such as, raw meat, or raw fish. H. After removal of medical/surgical or utility gloves. NOTE: Wash hands at end of procedures where glove changes are not required. For procedures in which change of gloves, e.g., clean gloves to sterile gloves to sterile gloves, is indicated follow the specific standard of practice. However, hand washing may not be necessary until completion of the procedure. If glove hands become contaminated as gloves are changed hands can be washed. I. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident in bed. J. Contact with environmental surfaces in the immediate vicinity of patients/residents. 2. Selection of Hand Hygiene/ Hand Hygiene/Hand washing Agent: A. When hands are visibly dirty or contaminated with proteinaceous materials or visibly soiled with blood or other body fluids wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based rub for routinely decontaminating hands in all other clinical situations. C. Before eating and after using a restroom wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. D. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternate to washing hands with non-antimicrobial soap and water. Follow manufacturer's recommendations for product use. E. Wash hands with non-antimicrobial soap and water or either antimicrobial soap and water if exposure to Dacilius anthracis is suspected or proven. 3. Method: Hand-Hygiene technique. A. When decontaminating hands with alcohol-based hand rub, apply product to palm of one hand and rub hands together covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's rec (TRUNCATED)