Every finding on record at Lawrence Co Nursing Center

Based on observation, interview, record review, and facility policy review the facility failed to ensure residents were treated with dignity, respect, privacy, and received necessary assistance with personal care in accordance with resident rights as evidenced by Resident #27 was unnecessarily exposed during catheter care and Resident #47 was denied requested assistance with drying beneath her breasts following a shower, resulting in prolonged moisture and a rash for two (2) of four (4) sampled residents for residents rights. (Resident #27 and Resident #47)Findings Include: Record review of the facility policy Residents Rights Policy with a revision date of 05/26 revealed, Every resident in this facility has the right to.11. Receive adequate care and appropriate healthcare, medical treatment and protective support services. 12. Be treated courteously, fairly and with fullest measures of dignity.17. Be treated with consideration and respect for their personal privacy including but not limited to. have facility staff personnel knock before entering their room. Record review of the facility policy Suprapubic Catheter Site Care with a review date of 01/24 revealed .Procedure.5. Assist resident to dorsal recumbent position and drape for privacy. Resident #27 On 06/17/26 at 10:06 AM, Licensed Practical Nurse (LPN) #4 was observed providing suprapubic catheter care for Resident #27. LPN #4 initially knocked on the door and explained the procedure to the resident. LPN #4 then exited the room to gather supplies and reentered without knocking. During care, LPN #4 pulled the resident's bed linens down to the knees, leaving the resident exposed from beneath her breasts to her knees. The exposure extended well beyond the suprapubic catheter site. The resident's vaginal area was exposed, and the resident was not draped for privacy. On 06/17/26 at 10:26 AM, during an interview, LPN #4 confirmed she did not knock upon reentering the room after obtaining supplies. LPN #4 stated she did not believe she needed to knock because she had already entered the room previously. LPN #4 stated the privacy curtain was closed. On 06/17/26 at 2:14 PM, during a follow-up interview, LPN #4 recanted her earlier statement and stated she had knocked both times before entering the room. LPN #4 stated that draping for privacy meant covering the resident during care and denied that Resident #27 had been exposed. LPN #4 stated the room door was closed and the privacy curtain was pulled. On 06/17/26 at 2:22 PM, during an interview, LPN #3 stated Resident #27's vaginal area should not have been exposed during suprapubic catheter care. LPN #3 stated LPN #4 failed to follow facility policy during the procedure. LPN #3 further stated staff should knock each time they enter a resident's room. On 06/17/26 at 3:05 PM, during an interview, Registered Nurse (RN) #1/Case Manager stated all staff are expected to knock each time they enter a resident's room. RN #1 stated LPN #4 should have draped the resident for privacy and only exposed the area necessary to provide catheter care. RN #1 stated staff are expected to follow facility policy when providing resident care. A record review of Resident #27's Face Sheet revealed an admission date of 3/18/19 with diagnoses including Neuromuscular Dysfunction of Bladder, Unspecified. A record review of Resident #27's Order Summary Report revealed an order dated 7/26/24 Cleanse area to suprapubic cath (catheter) with wound cleanser, pat dry, cover with split gauze, and secure with tape daily. A record review of Resident #27's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/26 revealed a Brief Interview for Mental Status (BIMS) score of five (5), indicating severe cognitive impairment. Resident #47 On 6/15/26 at 1:12 PM, during an interview, Resident #47 stated her only concern was her shower experience. The resident explained that she had difficulty drying herself after showering and specifically required assistance drying beneath her breasts because she could not adequately reach the area. The resident stated she had not previously asked staff for assistance because she felt it would be a bother. On 6/17/26 at 10:00 AM, during a follow-up interview, Resident #47 stated she requested assistance from Certified Nursing Assistant (CNA) #1 during her shower on 6/16/26 to dry beneath her breasts. Resident #47 reported CNA #1 told her she could not assist because it was a private area. Resident #47 stated she remained wet beneath her breasts following the shower. The resident reported the moisture caused a constant itchy and uncomfortable rash. Resident #47 stated she informed CNA #1 about the rash and was told to put some of your lotion on it. On 6/17/26 at 11:53 AM, during an interview, CNA #1 stated assisting residents with showering was part of her job responsibilities. CNA #1 stated this included washing and drying all body areas when residents required assistance. CNA #1 further stated Resident #47 informed her about a rash beneath her breast and that she reported the concern to LPN #1. On 6/17/26 at 12:01 PM, during an interview, LPN #1 stated that not any staff member had informed her of a rash beneath Resident #47's breast and that this was the first time she had heard of the concern. LPN #1 stated she would immediately notify the treatment nurse or Nurse Practitioner for assessment. On 6/17/26 at 12:11 PM, during an observation with the Nurse Practitioner, Resident #47 was observed to have a red, raised rash beneath her left breast. The Nurse Practitioner stated this type of rash can occur when moisture remains trapped beneath the breast. The Nurse Practitioner stated it is important for staff to thoroughly dry beneath the breasts during showering to help prevent skin irritation and breakdown. On 6/18/26 at 10:31 AM, during an interview, LPN #3, Staff Development Coordinator, stated CNAs are taught during training to provide residents with as much assistance as needed during showering and personal care. On 6/18/26 at 11:57 AM, during an interview, the interim Director of Nursing (DON) stated CNAs are expected to assist residents as needed during showers. The DON stated that drying beneath the breasts is important because moisture left in skin folds can cause skin irritation and breakdown. The DON further stated assisting residents with their needs is part of staff responsibilities. A record review of Resident #47's Face Sheet revealed the resident was admitted on [DATE] with diagnoses including Hypertensive Heart Disease with Heart Failure and Anxiety Disorder. A record review of Resident #47's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/26 revealed a Brief Interview for Mental Status (BIMS) score of (15), indicating the resident was cognitively intact.

Based on interview, record review, and facility policy review the facility failed to ensure residents were permitted to receive unopened mail and packages and failed to protect residents' rights to privacy and confidentiality for three (3) of (3) residents interviewed regarding receipt of mail (Residents #3, #9, and #32). This deficient practice had the potential to affect all residents residing in the facility who received mail or packages.Finding include: Record review of the facility policy, Resident Rights Policy, with a revision date of 5/26, revealed, Every resident in the facility has the right to: 17. Be treated with consideration and respect for their personal privacy .19. Receive unopened private mail .During an interview on 6/16/26 at 2:00 PM, the Activities Director mentioned that she had opened mail addressed to residents in the past. She explained that she was instructed to do so to ensure that residents were not ordering items that could be hazardous to their health. Additionally, she noted that she had been informed it was acceptable for nursing staff to open residents' mail at their discretion if they suspected a package contained something suspicious. The Activities Director now recognized that opening mail addressed to residents without their permission violated their rights.During an interview on 6/16/26 at 3:58 PM, Licensed Practical Nurse (LPN) #3 acknowledged it was a facility practice for staff to open resident mail. She stated the Social Services Director, and some other staff had been instructed to open resident packages if they had concerns regarding the contents.During an interview on 6/17/26 at 9:28 AM, Resident #32 mentioned that her brother frequently mailed packages to her from California. She noted that there had been occasions when packages addressed to her were opened prior to being delivered to her room. Although staff currently retaped the packages before delivery, it was still evident that they had been opened. Resident #32 expressed that she felt her privacy was being invaded and felt uneasy because she was unsure whether any items had been removed from the packages before they reached her.In an interview on 6/17/26 at 9:38 AM, Resident #3 indicated that facility staff had opened his mail. He noted that the staff member who opened the mail informed him she had always been told it was acceptable to open residents' mail. Resident #3 explained that he told the staff member that opening his mail violated his privacy rights and requested that staff discontinue the practice.In an interview on 6/17/26 at 1:55 PM, the son and resident representative of Resident #32 shared that he routinely sent his sister packages containing clothing, shoes, and snacks. He mentioned that Resident #32 had informed him that packages were being opened before she received them. After contacting the facility to inquire about why the packages were being opened, he was told it was standard practice to open all packages. The resident representative stated that after learning this, he reviewed each shipment with his sister upon delivery to ensure that all items originally sent remained in the package.In an interview on 6/17/26 at 3:00 PM, Resident #9 reported that some of her mail had been opened before it was delivered to her. She inquired with staff about why her mail had been opened and was told it was an accident. Resident #9 expressed skepticism about this explanation, noting that her name was clearly printed on the envelope. She stated that having her mail opened without permission made her feel terrible and violated her privacy.During an interview on 6/18/26 at 10:50 AM, the Administrator stated he was unsure where staff obtained the idea that they could open residents' mail without permission and acknowledged that doing so violated residents' rights to privacy.Resident # 9 A record review of the Face Sheet revealed the facility admitted Resident #9 on 9/6/25 with diagnoses including Type 2 Diabetes with Hyperglycemia. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/24/26 revealed a Brief Interview for Mental Status (BIMS) score of (15) indicating the Resident #9 is cognitively intact. Resident # 3A record review of the Face Sheet revealed the facility admitted Resident #3 on 6/26/25 with diagnoses including Primary Generalized OsteoarthritisA record review of the quarterly MDS with an ARD of 5/29/26 revealed a BIMS score of (15) indicating Resident #3 is cognitively intact.Resident # 32 A record review of Resident #32 Face Sheet revealed the facility admitted Resident #32 on 3/17/25 with diagnoses including Type 2 Diabetes with Hyperglycemia. A record review of the MDS with an ARD of 5/19/26 revealed a BIMS score of (14), indicating Resident #32 is cognitively intact.

Based on observation, interview, and record review, and facility policy review the facility failed to ensure physician orders contained complete and accurate medication dosage instructions for one (1) of five (5) residents reviewed for medication administration. (Resident #28). Findings Include:A record review of the facility policy Oral Medication Administration Procedure with a revision dated of 03/25 revealed, .2. Ensure that an appropriate physician's order is in place.Verify.b. right dosage. On 06/17/26 at 8:05 AM, Licensed Practical Nurse (LPN) #2 was observed administering medications to Resident #28. During the observation, the physician order for Vitamin D3 was reviewed and directed staff to give one tablet daily. The order did not contain a dosage strength. LPN #2 administered (1) Vitamin D3 125 mcg (microgram) tablet to Resident #28.On 06/17/26 at 8:08 AM, LPN #2 was interviewed regarding the medication administration. LPN #2 stated there were two Vitamin D products available on the medication cart. LPN #2 presented one bottle labeled Vitamin D3 125 mcg and a second bottle labeled Vitamin D. Further review of the second bottle revealed Vitamin D3 as the active ingredient with a strength of 25 mcg. When asked how she determined which medication to administer, LPN #2 stated she selected the product labeled Vitamin D3. After reviewing the second bottle, LPN #2 acknowledged that both products contained Vitamin D3 and stated the physician order required clarification to ensure the resident received the correct prescribed dose.During an interview on 06/17/26 at 1:51 PM, the Interim Director of Nursing (IDON) stated the medication should have been held and the physician contacted for clarification before administration. The IDON stated the order had been written incorrectly and required clarification. The IDON further stated nurses should not independently determine which dosage of a medication to administer when the physician order is incomplete. The IDON stated potential consequences included administration of an excessive dose resulting in toxicity or administration of an insufficient dose that failed to meet the resident's clinical needs.A record review of the June 2026 Medication Administration Record (MAR) revealed nurse initials indicating that Resident #28 had received Vitamin D3 on 6/17/26.A record review of the Face Sheet revealed Resident #28 was admitted on [DATE] with a diagnose that included Other Paralytic Syndrome Following Cerebral Infarction Affecting Left Non-Dominant Side.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/1/26 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #28 had moderate cognitive impairmentA record review of Resident #28's Order Summary Report revealed an order dated 12/31/20 for Vitamin D3 Oral Tablet Give (1) tablet give 1 tablet by mouth one time a day related to Vitamin D deficiency.

Based on observation, interview, facility policy review and record review, the facility failed to ensure a resident received appropriate perineal care and in accordance with professional standards of practice for one (1) of three (3) residents reviewed for personal hygiene care (Resident #45). Findings Include:Record review of the facility policy Perineal Care with a revision date of 01/24 revealed .Preparing For Care.6. Perform hand hygiene and apply gloves . 5. Wash genital area, moving from front to back while using a clean portion of the washcloth or pre-moistened wash wipe for each stroke. 6. When soap is used, rinse genital area rinsing area moving front to back using a clean portion of the washcloth or premoistened wash wipe for each stroke. 7. Dry genital area moving from front to back with towel. 8. Assist the resident to turn onto side facing away from you with leg slightly bent at the knee. 9. With a new washcloth or premoistened wash wipe, clean the anal area from front to back using a clean area of the washcloth or premoistened wash wipe after each stroke. 10. When soap is used, rinse genital area moving from front to back using a clean portion of the washcloth or premoistened wash wipe for each stroke. 11. Dry area using same method .On 06/16/26 at 2:40 PM, Certified Nursing Assistant (CNA) #2, assisted by CNA #3, was observed providing peri-care to Resident #45. Prior to care, CNA #2 obtained supplies from a linen cart in the hallway including a lift pad, brief, and towels. Either of the CNAs did not perform hand hygiene before initiating care or during the procedure. During care, CNA #2 turned on the faucet while wearing gloves, wet a hand towel, and applied soap. CNA #3 lowered the bed linens and removed the residents' brief. CNA #3 cleansed the residents' left and right thigh areas using a single front-to-back stroke with the same soapy washcloth. CNA #3 then cleansed the vaginal area one time without folding the washcloth or using a clean portion of the cloth for each stroke. After cleansing the vaginal area, the CNAs failed to rinse soap from the resident's skin and immediately dried the resident with a towel. CNA #3 then turned the resident onto her left side. CNA #2 flipped the same wet soapy washcloth over one time and cleansed the buttocks area using a single front-to-back stroke before drying the area. The CNAs did not use a basin of clean water, did not rinse the washcloth between uses, did not rinse soap from the resident's skin, did not perform hand hygiene during care, and did not wear gowns despite physician orders requiring Enhanced Barrier Precautions during hygiene care. Following completion of care, the CNAs removed their gloves and performed hand hygiene in the hallway.On 06/16/26 at 2:47 PM, during an interview, CNA #3 confirmed perineal care was not completed correctly. CNA #3 stated she was nervous and forgot the proper procedure. CNA #3 acknowledged the deficient care placed the resident at risk for infectionOn 06/16/26 at 2:50 PM, during an interview, CNA #2 confirmed she and CNA #3 did not wear gowns, did not use a barrier, did not use a basin, and did not perform hand hygiene before or during care. CNA #2 stated she believed Resident #45 did not have a basin available. CNA #2 acknowledged that peri-care was not completed according to facility policy and confirmed soap was not rinsed from the resident's skin.On 06/16/26 at 2:59 PM, an observation of Resident #45's closet with CNA #2 and CNA #3 revealed a basin was present. CNA #2 stated she was unaware the resident had a basin. CNA #2 acknowledged the basin should have been used and stated the care provided exposed Resident #45 to cross contamination and infection. CNA #2 again stated she was nervous and forgot the proper procedure.On 06/17/26 at 2:34 PM, during an interview, Licensed Practical Nurse (LPN) #3/ Infection Preventionist, stated staff should have used a basin during care and should have rinsed soap from the resident's skin before drying. LPN #3 stated the CNAs failed to follow facility policy throughout the procedure. LPN #3 stated the resident was placed at risk for infection, including urinary tract infection, and that failure to wear gowns during Enhanced Barrier Precaution care increased the risk of cross contamination to other residents. LPN #3 stated the care provided placed Resident #45 at increased risk for infection.On 06/17/26 at 3:10 PM, during an interview, Registered Nurse (RN) #1, Case Manager, stated staff should have used a basin to properly provide care. RN #1 stated hand hygiene should have been performed before, during, and after care. RN #1 stated the washcloth should have been rinsed before continued use and soap should have been rinsed from the resident's skin before drying. RN #1 stated staff failed to follow facility policy during the entire procedure. RN #1 stated the deficient practice placed the resident at risk for urinary tract infection, skin irritation, and skin breakdown. RN #1 stated her expectation was that all staff provide care according to facility policy and accepted standards of practice.Record review of the Face Sheet revealed an admission date of 11/13/23 with diagnoses that included Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Non-Dominant side and encounter for attention to colostomy.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/26 revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated severe cognitive impairment.Record review of the Order Summary Report with active orders as of 6/17/26 revealed an order dated1/17/26 Enhanced Barrier Precautions- gown and gloves to be worn during high contact resident care activities.hygiene, changing briefs.Clean stoma with soap and water pat dry wipe skin around stoma with skin prep .

Based on interview, observation, and record review, the facility failed to accommodate food preferences for one (1) of (15) residents reviewed for food and nutrition services. (Resident #32). Findings Include:On 06/15/26 at 12:09 PM, during an interview, Resident #32 stated she had requested two (2) boiled eggs, (2) slices of bacon, and oatmeal for breakfast. Resident #32 stated she spoke with the Dietary Manager (DM), who agreed to provide the requested breakfast items. The resident stated she only received the requested breakfast one time after making the request.On 06/16/26 at 11:20 AM, during an interview, Resident #32 stated she was served (1) slice of bacon, scrambled eggs, (1) slice of toast, and oatmeal. Resident #32 stated (2) boiled eggs were handwritten on her tray card but were not included on her meal tray. Resident #32 stated she wanted the breakfast items she had requested.On 06/17/26 at 7:53 AM, an observation of Resident #32's breakfast tray revealed grits, scrambled eggs, sausage patty, and biscuits. The tray did not contain bacon, oatmeal, or boiled eggs as requested by the resident.On 06/17/26 at 11:02 AM, during an interview, the Dietary Manager stated Resident #32 had requested breakfast changes and the requested items had been added to the tray card. The Dietary Manager stated Resident #32 did not receive boiled eggs on 06/15/26 or 06/17/26 because the cook did not prepare them. The Dietary Manager further stated Resident #32 did not receive boiled eggs on 06/16/26 because the facility had run out of eggs. The Dietary Manager stated a food delivery arrived on the evening of 06/16/26 and eggs were available on 06/17/26. The Dietary Manager stated there was no reason Resident #32 should not have received the requested boiled eggs when they were available and acknowledged the resident's needs should have been met.On 06/18/26 at 1:40 PM, during an interview, the Nursing Home Administrator (NHA) stated he expected dietary staff to provide residents with their requested food preferences whenever possible. The NHA stated, This is the resident's home.A record review of the Face Sheet revealed an admission date of 3/17/25 with diagnoses that included Type 2 Diabetes Mellitus Hyperglycemia and Morbid (Severe) Obesity Due to excess calories.A record review of the Order Summary Report revealed a physician order dated 3/17/25, LCS/NSOT (Low Concentrated Sweets/No salt on tray) diet, Regular texture, Regular consistency.A record review of Resident #32's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact.

Based on observations, interviews, record review and facility policy review the facility failed to prevent the possibility of spreading infection during perineal care for one (1) of four (4) care observations. Resident #45. Findings Include:Record review of the facility policy Hand Hygiene with a revision date of 01/24 revealed Purpose: To cleanse hands to prevent transmission of infection or other conditions. To provide clean health environment for residents, staff and visitors .Procedure. 2. Hand hygiene should be performed between all contacts with residents or when entering and exiting a resident's room. 3. Before and after procedures 3. Before and after applying gloves.Record review of the facility's Enhanced Barrier Precaution signage revealed EVERYONE MUST Clean their hands, including before entering and when leaving the room. Wear gloves and a gown for the following high contact Resident Care Activities . Changing briefs or assisting with toileting.Record review of the facility policy Enhanced Barrier Precautions (EBP) with a revision date of 3/24 revealed . EBP involves gown and gloves use during high-contact resident care activities for residents known to be colonized .For resident for whom EBP are indicated, EBP is employed when performing the following.Changing briefs or assisting with toileting.During an observation on 06/16/26 at 2:40 PM, Certified Nursing Assistant (CNA) #2, assisted by CNA #3, was observed providing peri-care to Resident #45. Prior to care, CNA #2 obtained supplies from a linen cart in the hallway including a lift pad, brief, and towels. Either of the CNAs did not perform hand hygiene before initiating care or during the procedure. During care, CNA #2 turned on the faucet while wearing gloves, wet a hand towel, and applied soap. CNA #3 lowered the bed linens and removed the residents' brief. CNA #3 cleansed the residents' left and right thigh areas using a single front-to-back stroke with the same soapy washcloth. CNA #3 then cleansed the vaginal area one time without folding the washcloth or using a clean portion of the cloth for each stroke. After cleansing the vaginal area, the CNAs failed to rinse soap from the resident's skin and immediately dried the resident with a towel. CNA #3 then turned the resident onto her left side. CNA #2 flipped the same wet soapy washcloth over one time and cleansed the buttocks area using a single front-to-back stroke before drying the area. The CNAs did not use a basin of clean water, did not rinse the washcloth between uses, did not rinse soap from the resident's skin, did not perform hand hygiene during care, and did not wear gowns despite physician orders requiring Enhanced Barrier Precautions during hygiene care. Following completion of care, the CNAs removed their gloves and performed hand hygiene in the hallway.During an interview on 06/16/26 at 2:47 PM, CNA #3 confirmed peri-care was not completed correctly. CNA #3 stated she was nervous and forgot the proper procedure. CNA #3 acknowledged the deficient care placed the resident at risk for infection.During an interview on 06/16/26 at 2:50 PM, CNA #2 confirmed she and CNA #3 did not wear gowns, did not use a barrier, did not use a basin, and did not perform hand hygiene before or during care. CNA #2 stated she believed Resident #45 did not have a basin available. CNA #2 acknowledged that peri-care was not completed according to facility policy and confirmed soap was not rinsed from the resident's skin.During an observation on 06/16/26 at 2:59 PM, of Resident #45's closet with CNA #2 and CNA #3 revealed a basin was present. CNA #2 stated she was unaware the resident had a basin. CNA #2 acknowledged the basin should have been used and stated the care provided exposed Resident #45 to cross contamination and infection. CNA #2 again stated she was nervous and forgot the proper procedure.During an interview on 06/17/26 at 2:34 PM, Licensed Practical Nurse (LPN) #3/ Infection Preventionist, stated staff should have used a basin during care and should have rinsed soap from the resident's skin before drying. LPN #3 stated the CNAs failed to follow facility policy throughout the procedure. LPN #3 stated the resident was placed at risk for infection, including urinary tract infection, and that failure to wear gowns during Enhanced Barrier Precaution care increased the risk of cross contamination to other residents. LPN #3 further stated contaminated linens should have been bagged and not placed against staff uniforms. LPN #3 stated the care provided placed Resident #45 at increased risk for infection.During an interview on 06/17/26 at 3:10 PM, Registered Nurse (RN) #1, Case Manager, stated staff should have used a basin to properly provide care. RN #1 stated hand hygiene should have been performed before, during, and after care. RN #1 stated the washcloth should have been rinsed before continued use and soap should have been rinsed from the resident's skin before drying. RN #1 stated staff failed to follow facility policy during the entire procedure. RN #1 stated the deficient practice placed the resident at risk for urinary tract infection, skin irritation, and skin breakdown. RN #1 stated her expectation was that all staff provide care according to facility policy and accepted standards of practice.Record review of the Face Sheet revealed an admission date of 11/13/23 with diagnoses that included Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Non-Dominant side and encounter for attention to colostomy.Record review of the Order Summary Report with active orders as of 6/17/26 revealed an order dated1/17/26 Enhanced Barrier Precautions- gown and gloves to be worn during high contact resident care activities.hygiene, changing briefs.Clean stoma with soap and water pat dry wipe skin around stoma with skin prep . A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 6/1/26 revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicates severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to provide wound care in accordance with professional standards of practice and physician's orders, specifically failing to cleanse wounds with proper technique and dry wounds prior to dressing application, and placing a resident (Resident #2) in two (2) briefs, which increased the risk for skin breakdown and infection, for (2) of three (3) sampled residents reviewed for wound care (Residents #2 and #3).Findings include:A record review of the facility's Dressing Change Policy and Procedure with a review date of 8/21 revealed, .Steps in the Procedure.14. Dry the skin surrounding the area by patting with a soft 4 X (by) 4.Resident #2On 9/4/25 at 9:50 AM, an observation of Licensed Practical Nurse (LPN) #1 providing wound care revealed Resident #2 was wearing two briefs. LPN #1 removed the soiled dressing and cleansed the hip wound by wiping back and forth across the wound bed multiple times with the same gauze rather than discarding it after a single pass. A second gauze was used in the same manner. LPN #1 did not pat the wound dry prior to applying Santyl, gentamicin, nystatin powder, calcium alginate, and foam dressing as ordered. LPN #1 repeated the same technique when cleansing the sacral wound, wiping back and forth with gauze, and again did not dry the wound before applying calcium alginate and foam dressing.A record review of the admission Record revealed the facility admitted Resident #2 on 12/24/20 with diagnoses including a Pressure Ulcer. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impairedA record review of the Order Summary Report revealed Resident #2 had a Physician's Order, dated 7/4/25 to Cleanse excoriated area to the right hip with wound cleanser, pat dry, apply Santyl ointment.and Hydrofera blue classic daily to the wound. Secure with adhesive foam until healed. There was also an order dated 8/22/25 to Cleanse stage 3 pressure ulcer to sacrum with wound cleanser, pat dry, apply santyl, gentamicin 0.1%, nystatin powder calcium alginate and cover with border foam dressing daily.Resident #3On 9/4/25 at 10:35 AM, an observation of Resident #3 receiving wound care revealed LPN #1 cleansed the sacral wound using gauze soaked in wound cleanser, then inserted gauze into the wound bed with a cotton swab, and applied calcium alginate without patting the wound dry as ordered.A record review of the Order Summary Report revealed Resident #3 had a Physician's Order, dated 6/20/25, to Cleanse Stage 2 pressure wound to the sacrum with wound cleanser, pat dry, lightly pack calcium alginate to the wound and secure with adhesive foam until healed.On 9/4/25 at 10:23 AM, during an interview with Certified Nursing Assistant (CNA) #1, she stated that placing two briefs on a resident was against her training and could contribute to skin breakdown or rash.On 9/4/25 at 11:04 AM, during an interview with Licensed Practical Nurse (LPN) #1, she acknowledged that she did not pat dry the wounds prior to applying the dressings and confirmed that she did not follow the physician's orders. She stated she did not clean Resident #2's wound correctly and thought she had folded or flipped the gauze. She explained that a wound should be dried before covering to reduce the risk of further breakdown and infection. She acknowledged that her actions placed the residents at risk for infection. She also stated that no resident should be double briefed, as doing so can irritate the skin.On 9/4/25 at 12:11 PM, during an interview, the Director of Nursing (DON) stated that residents should never be double briefed because it can contribute to skin breakdown. She further explained that wounds should be cleaned using either a top-to-bottom or circular motion, discarding gauze after each use. She stated wounds must always be dried before dressing application, and that failure to do so could result in moisture contributing to skin breakdown or infection.On 9/4/25 at 2:00 PM, during an interview, CNA #2 stated she had provided perineal care for Resident #3 earlier that morning and acknowledged that she had placed two briefs on the resident. CNA #2 stated she had previously received in-service training on the risks of double briefing.A record review of the admission Record revealed the facility admitted Resident #3 on 3/18/19 with current diagnoses including a Pressure Ulcer. A record review of the Quarterly MDS with an ARD of 7/7/25 revealed Resident #3 had a BIMS score of 4, which indicated the resident was severely cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions during wound care for two (2) of (2) wound care observations (Residents #2 and #3).Findings include:A review of the facility's policy, Care Plan Process, with a review date of 12/24, revealed, .The comprehensive care plan is an interdisciplinary communication tool.The facility staff shall follow the care plan.Resident #2A record review of the Order Summary Report revealed Resident #2 had a physician's order, dated 7/4/25, to Cleanse excoriated area to the right hip with wound cleanser, pat dry, apply Santyl ointment . and Hydrofera blue classic daily to the wound. Secure with adhesive foam until healed. There was also an order, dated 8/22/25, to Cleanse stage 3 pressure ulcer to sacrum with wound cleanser, pat dry, apply Santyl, gentamicin 0.1%, nystatin powder, calcium alginate and cover with border foam dressing daily.A record review of the Care Plan Report revealed a Resident #2 had Interventions including .Cleanse Stage 3 Pressure Ulcer to Sacrum with Wound Cleanser, Pat Dry. and Cleanse excoriated area to the Rt (Right) hip with wound cleanser, pat dry.On 9/4/25 at 9:50 AM, during an observation of wound care provided to Resident #2, Licensed Practical Nurse (LPN) #1 did not pat the wound on the right hip dry before applying Santyl, gentamicin, nystatin powder, calcium alginate, and foam dressing. LPN #1 also did not dry the sacral wound before applying calcium alginate and foam dressing, contrary to the physician's orders and the resident's care plan.A record review of the admission Record revealed the facility admitted Resident #2 on 12/24/20 with diagnoses including a Pressure Ulcer.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired.Resident #3A record review of the Care Plan Report revealed Resident #3 had Interventions including Cleanse Stage 2 to sacrum with wound cleanser, pat dry.A record review of the Order Summary Report revealed Resident #3 had a physician's order, dated 6/20/25, to Cleanse Stage 2 pressure wound to the sacrum with wound cleanser, pat dry, lightly pack calcium alginate to the wound and secure with adhesive foam until healed.On 9/4/25 at 10:35 AM, during an observation of wound care for Resident #3, LPN #1 cleansed the sacral wound with gauze soaked in wound cleanser, inserted gauze into the wound bed with a cotton swab and applied calcium alginate without patting the wound dry as ordered and care planned.On 9/4/25 at 11:04 AM, during an interview, LPN #1 acknowledged that she did not pat dry the wounds prior to applying the dressings and confirmed she did not follow the physician's orders or the care plan.On 9/4/25 at 3:25 PM, during an interview, the Director of Nursing (DON) stated LPN #1 did not follow the care plan during wound care for Residents #2 and #3. She stated her expectation is that all staff follow the care plan when providing care to residents.On 9/4/25 at 4:34 PM, during an interview, Registered Nurse (RN) #1, the MDS/Case Manager, stated that staff should follow the care plan, which is developed to direct resident care. She confirmed LPN #1 did not follow the care plan and explained that the care plan is designed to inform staff of the resident's care needs.A record review of the admission Record revealed the facility admitted Resident #3 on 3/18/19 with diagnoses including a Pressure Ulcer.A record review of the Quarterly MDS with an ARD of 7/7/25 revealed Resident #3 had a BIMS score of 4, which indicated the resident was severely cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices by placing wound care supplies on an undisinfected bedside table during treatment, creating the potential for cross-contamination and infection, for one (1) of two (2) wound care observations (Resident #3).Findings include:A review of the facility's policy, Infection Control, revised 4/21, revealed The facility will maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment with minimal exposure to the transmission of disease and infection.On 9/4/25 at 10:35 AM, during an observation of wound care provided to Resident #3's sacral wound, Licensed Practical Nurse (LPN) #1 entered the resident's room with supplies carried on a white disposable barrier. She placed the barrier on the foot of the resident's bed, then placed a bottle of hand sanitizer and clean gloves directly on the resident's bedside table without disinfecting the surface. LPN #1 donned (put on) gloves, then removed the resident's soiled dressing and placed it in a biohazard bag. She then removed her gloves, sanitized her hands, and reapplied gloves obtained from the bedside table. LPN #1 repeated this process four times, each time retrieving gloves and sanitizer from the undisinfected bedside table before continuing wound care.On 9/4/25 at 11:04 AM, during an interview, LPN #1 confirmed she did not disinfect the bedside table before placing wound care supplies on it. She stated she should have cleaned the table before and after wound care and acknowledged her actions placed the resident at risk for infection.On 9/4/25 at 12:24 PM, during an interview, the Director of Nursing (DON) stated LPN #1 should have disinfected the bedside table and used a barrier before placing supplies on it. She explained that failure to follow this practice could lead to infection.On 9/4/25 at 2:23 PM, during an interview, LPN #2, the facility's Infection Preventionist (IP) nurse, confirmed that no items should be placed on a bedside table without first disinfecting it. She stated that germs present on the surface could be transferred to the gloves and sanitizer bottle, then carried to the resident's wound during care, creating a risk of infection.A record review of the admission Record revealed the facility admitted Resident #3 on 3/18/19 with current diagnoses including a Pressure Ulcer of sacral region, stage 2.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/25 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident was severely cognitively impaired.A record review of the Order Summary Report revealed Resident #3 had a physician's order, dated 6/20/25, to Cleanse Stage 2 pressure wound to the sacrum with wound cleanser, pat dry, lightly pack calcium alginate to the wound and secure with adhesive foam until healed.

Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to review and revise the resident's pain to reflect actual pain instead of at risk for pain for one (1) of seventeen (17) residents reviewed for pain. Resident #44. Findings include: Record review of the facility's Care Plan Process, with a revision date of 12/24, revealed The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to review and revise each resident's comprehensive person-centered plan of care. Record review of Resident #44 ' s Care Plan Report with a date initiated of 12/5/24 revealed Focus: The resident IS AT RISK FOR PAIN. This care plan had not been revised to reflect Resident #44's ACTUAL pain. On 03/30/25 at 11:35 AM, during an observation and interview, Resident #44 stated he is in constant pain due to skin cancer. Resident #44's right arm was wrapped in Kerlix. He stated they only give him Tylenol and that it does not help. He described the pain as feeling like ants are biting him and stated he is in pain all the time. He reported telling the nurse that Tylenol does not help and rated his pain as an eight (8) on a scale of 0-10 with 10 being the greatest pain. On 04/01/25 at 7:52 AM, during an interview, Resident #44 stated his pain level was at a nine (9). He reported calling for pain medication three times before the nurse finally gave him something for pain the previous night. He stated the nurse told him she could not give him anything because it was not time yet. He said he was in pain all night and had trouble sleeping. He repeated that he is in constant pain and all he receives is Tylenol. On 04/01/25 at 03:04 PM, during an interview, Licensed Practical Nurse (LPN) #4 stated that Resident #44 has skin cancer and that's what all the sores are on him. On 04/02/25 at 10:57 AM, Resident #44 was observed lying in bed watching TV. He stated he had received Tylenol that morning and his current pain level was a 7. He stated that without Tylenol, his pain is typically at an eight to nine (8-9). On 04/02/25 at 11:02 AM, during an interview, LPN #3 stated that when Resident #44 complains about pain, she gives him Tylenol. She confirmed Tylenol is now scheduled. She stated the resident was previously receiving Tylenol as needed and that it was changed to a scheduled dose on 03/19/25 to help manage his pain. She could not recall where she had documented the resident's pain relief. On 04/02/25 at 11:32 AM, during an interview, the DON stated the comprehensive care plan should have been updated from at risk for pain to reflect actual pain. She stated she expects nurses to follow up with the resident after administering pain medication and to document the outcome. On 04/02/25 at 12:18 PM, during an interview, Registered Nurse (RN) #1, the MDS/Care Plan Nurse, stated she just noticed the care plan should have been updated. She confirmed that the care plan is used by all staff. Record review of Resident #44's Admission Record revealed an admitted [DATE] with diagnoses of localized infection of the skin and subcutaneous tissue, pain, leukemia (unspecified and not in remission), and basal cell carcinoma of the skin (unspecified). Record review of Resident #44's Order Summary Report with active orders as of 4/2/25 revealed a physician order dated 03/19/25 Acetaminophen Tablet 325 mg - Give 2 tablets by mouth three times a day, related to pain. Record review of Resident #44's Physician Consultation Report from Resident #44's Dermatologist dated 10/29/24 revealed Findings: Basal cell carcinoma of the left forearm, excised; Spots of concern x 2 right temple, left chest. Referral to plastic surgery for right forearm for squamous cell carcinoma. Review of the Minimum Data Set (MDS) for Resident #44 with an Assessment Reference Date (ARD) of 02/24/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section J indicated the resident experienced pain almost constantly and that pain affected sleep almost constantly. Section M documented open skin lesions.

Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to manage the resident's pain to the extent possible in accordance with professional standards and the resident's goals and preferences for one (1) of seventeen (17) residents reviewed for pain, Resident #44. Findings include: Record review of the facility's Pain Screen and Management policy, with a revision date of 12/23, revealed: All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of pain relief is achieved. All residents have the right to treatment for pain. Resident preferences are respected when deciding on methods to be used for pain management. The residents' statements are the most valid measurements of pain. 4.b New or changed medication orders are transcribed per facility standards of practice and a clinical note is documented 4.d. When the resident is medicated with the prescribed medication or treated as ordered, documentation of medication or treatment is done on the electronic Treatment Administration Record (TAR). 4.e. Documentation using the pain scale of a new type of pain, a pain medication and/or treatment change is completed every shift until the pain is managed effectively . 6.a. A pain scale is completed on the Electronic Medication Administration Record (eMAR)/Electronic Treatment Administration Record (eTAR.) . During an observation and interview on 03/30/25 at 11:35 AM, Resident #44 stated he is in constant pain due to skin cancer. Resident #44's right arm was wrapped in Kerlix. He stated they only give him Tylenol and that it does not help. He described the pain as feeling like ants are biting him and stated he is in pain all the time. He reported telling the nurse that Tylenol does not help and rated his pain as an eight (8) on a scale of 0-10 with 10 being the greatest pain. During an interview on 04/01/25 at 7:52 AM, Resident #44 stated his pain level was at a 9. He reported calling for pain medication three times before the nurse finally gave him something for pain the previous night. He stated the nurse told him she could not give him anything because it was not time yet. He said he was in pain all night and had trouble sleeping. He repeated that he is in constant pain and all he receives is Tylenol. During an interview on 04/01/25 at 3:04 PM, during an interview, Licensed Practical Nurse (LPN)# 4 stated that Resident #44 has skin cancer and stated that's what all the sores are on him. She reviewed his diagnoses and confirmed that Resident #44's diagnosis of skin cancer was not in the chart. During an observation, Resident #44 was observed lying in bed watching television on 04/02/25 at 10:57 AM. He stated he had received Tylenol that morning and his current pain level was a 7. He stated that without Tylenol, his pain is typically at eight to nine (8-9). During an interview on 04/02/25 at 11:02 AM, LPN #3 stated that when Resident #44 complains of pain, she gives him Tylenol. She confirmed Tylenol is now routine. She stated the resident previously received Tylenol as needed, and it was changed to routine on 03/19/25 to help with his pain. She could not recall where she documented the resident's pain relief. On 04/02/25 at 11:08 AM, during an interview, the Nurse Practitioner (NP) stated she is in the facility three days a week and sees all residents once a week. She stated she had not seen Resident #44 yet this week but was aware of his skin cancer. She stated he receives routine Tylenol for pain. She added that a pain level of seven (7) while on medication indicates the treatment is not effective. On 04/02/25 at 11:32 AM, during an interview, the DON stated that Resident #44 had been seen by a dermatologist. She confirmed that a pain level of 7 with medication is not effective. She stated that when nurses give pain medication, they are expected to reassess the resident's pain level 30 minutes after administration and document the outcome. She stated the eMAR should have a pain scale attached to the order and that it was not attached in April. She stated the pain scale provides a place for nurses to document the effectiveness of pain medication. She also confirmed that there were no progress notes related to pain and stated this documentation is expected. The DON stated that if the pain medication is not effective, staff must document it and notify the NP for a new order. Record review of Resident #44's Admission Record revealed an admitted [DATE] with diagnoses of local infection of the skin and subcutaneous tissue, pain, unspecified leukemia not in remission, and basal cell carcinoma of the skin (unspecified). Record review of Resident #44's Order Summary Report with active orders as of 4/2/25 revealed a physician order dated 03/19/25, Acetaminophen Tablet 325 mg - Give 2 tablets by mouth three times a day, related to pain. Record review of the March 2025, eMAR revealed that from 03/20/25 to 03/31/25, Resident #44 received Acetaminophen 325 mg (milligrams)tablets three times daily; however, pain levels were not documented. This section was left blank. The previous as needed Tylenol order was discontinued on 03/19/25. Record review of the April 2025 eMAR revealed that Resident #44 received Acetaminophen 325 mg tablets three times daily on 04/01/25 and 04/02/25. Pain levels were not documented. Record review of Resident #44's Progress Notes dated from 03/01/25 to 04/02/25 revealed no documentation related to pain. Record review of Resident #44 's Physician Consultation Report from Resident #44's Dermatologist dated 10/29/24 revealed Findings: Basal cell carcinoma of the left forearm, excised Spots of concern x 2 right temple, left chest .Referral to plastic surgery for right forearm for squamous cell carcinoma. Review of the Minimum Data Set (MDS) for Resident #44, with an Assessment Reference Date (ARD) of 02/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact. Section J indicated the presence of pain almost constantly, with pain affecting sleep almost constantly. Section M documented open skin lesions.

Based on interviews, facility statement review and Certification and Survey Provider Enhanced Reports (CASPER) data review, the provider failed to ensure their Payroll Based Journal (PBJ)-which includes information on the staffing hours necessary for the appropriate care of the residents-was corrected prior to submission to the Centers for Medicare & Medicaid Services (CMS) for one (1) of four (4) quarters in 2024. (October 1-December 31.) Findings include: Record review of a statement of facility letterhead, undated, and signed by the facility Administrator, revealed There has been an upgrade to the timeclock system which has created some glitches that may have caused reporting issues. During an interview with the Human Resources Director on April 2, 2025, at 2:30 PM, she stated that nursing hours are automatically sent to the Payroll Based Journal (PBJ) when staff clock in. She reported that she only enters agency nursing hours and does not have direct access to the PBJ or receive any notifications regarding submission errors. On April 2, 2025, at 2:45 PM, the Administrator stated that he verifies the accuracy of the PBJ prior to submission. He explained that the corporate office receives notifications about submission errors, such as low weekend staffing. He stated that the facility recently upgraded its time clock system and speculated that ongoing glitches in the system may have contributed to errors in PBJ reporting.

Based on staff interviews, record reviews, facility policy review and Plan of Correction (POC) review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies originally cited during the recertification survey conducted in February 2024, for two (2) of eight (8) deficiencies cited on the current recertification survey. Findings include: A review of the facility policy, Five Elements of QAPI, revised 11/22, revealed the following: Element 3: Feedback, Data Systems and Monitoring - the facility puts systems in place to monitor care and services It also includes tracking, investigating, and monitoring . and corrective action plans implemented to prevent recurrences . F851 - Payroll-Based Journal Reporting During this recertification survey, the provider failed to ensure their Payroll Based Journal (PBJ)-which documents staffing hours required to provide appropriate care to residents-was corrected before submission to the Centers for Medicare & Medicaid Services (CMS) for one (1) of four (4) quarters in 2024. During the recertification survey in February 2024, the provider failed to ensure PBJ reporting was corrected before submission to CMS for one (1) of four (4) quarters in 2023. F880 - Infection Prevention and Control During this recertification survey, the facility failed to prevent the possible spread of infection by not exercising proper hand hygiene during perineal care for two (2) of three (3) residents observed. During the recertification survey in February 2024, the facility failed to prevent the possible spread of infection by not exercising proper hand hygiene during perineal care for one (1) of fifteen (15) sampled residents observed. On 04/02/25 at 2:27 PM, in an interview with the Director of Nursing (DON), she confirmed that the facility had been cited for the same infection control issue during the previous year's survey. She explained that it is not due to a lack of inservice training but stated they may need to rethink their approach. She suggested implementing more supervision while staff are providing care. She added that although high-risk meetings are held, they do not address infection control tasks like this. On 04/02/25 at 2:31 PM, during an interview with the Staffing Coordinator, she acknowledged that the facility had been cited for the same infection control issues. She stated that while inservices are provided, she believes the frequency of training on hand hygiene and glove use should be increased. On 04/02/25 at 2:45 PM, in an interview with the Administrator, he stated that recurring infection control issues are largely due to the need for increased staff monitoring. The Administrator confirmed there were errors in PBJ reporting during the prior recertification survey. He stated that the issue persists due to a recent upgrade to their time clock system. He suggested there may be a transmission problem between the time clock and the PBJ reporting system.

Based on observation, interview, record review, and policy review, the facility failed to follow proper infection control guidelines for two (2) of three (3) care observations. Resident# 5 and Resident #44. Findings include: Record review of the facility policy Enhanced Barrier Precautions (EBP) last reviewed 03/24 revealed .Enhanced Barrier Precautions are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO (Multidrug Resistant Organisms) . Record review of the facility policy titled Hand Hygiene revised 08/14/24 revealed .2. Hand hygiene should be performed between all contact with residents, or when entering and exiting a resident ' s room .4. before and after applying gloves, 5. when hands are visibly soiled 9. Wearing gloves does not replace the need to perform hand hygiene Resident #5 On 04/01/25 at 10:18 AM, Resident #5 was observed during wound care to the sacral area. At this time, Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #2 were present and performing the wound care. Neither staff member was wearing gowns. Prior to the wound care, the resident had soiled her brief with urine. CNA #2 notified the nurse. However, wound care was observed being provided and completed prior to staff changing the resident's brief. After changing the brief, staff did not perform perineal care. On 04/01/25 at 10:30 AM, LPN #3 verified during an interview, that she did not wear a gown. She stated the resident is on Enhanced Barrier Precautions, therefore a gown should have been worn by herself and CNA #2 during care. She also stated that perineal care should have been performed at the time the brief was changed and that the brief should have been changed before wound care was initiated to prevent infection. On 04/01/25 at 10:32 AM, CNA #2 stated that the resident's brief should have been changed prior to performing wound care and that she should have performed perineal care prior to leaving the room, rather than just changing the brief. She acknowledged that this was necessary to prevent infection due to the resident's incontinent episode of urine. She also stated she should have worn a gown before entering the room to provide care. Record review Admission record revealed Resident #5 was admitted on [DATE] with a diagnoses that included Schizoaffective disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/8/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section M documented a Stage 2 pressure injury. Record review of Order Summary Report with active orders as of 4/1/25 revealed a physician order dated 3/7/25, Cleanse Stage 2 pressure wound to the sacral area with wound cleanser, pat dry, apply Nystatin powder (around the peri-wound), apply Duoderm, and cover with foam dressing daily until healed. Resident #44 On 04/01/25 at 3:30 PM, Resident #44 was observed receiving perineal care. CNA #1 provided the care. During the process, she was observed cleaning stool from the resident using a brief. She had gloves on. She then wrapped the stool in the brief, placed it in a receptacle, and left the bedside wearing the same soiled gloves. She touched multiple surfaces, turned on the sink faucet, and applied soap to a new towel to clean the resident, all while still wearing the soiled gloves. On 04/02/25 at 9:25 AM, CNA #1 was interviewed and confirmed that she should have removed her soiled gloves prior to leaving the bedside to avoid possibly spreading contamination from stool to the sink and anything else she touched. On 04/02/25 at 10:11 AM, the Director of Nursing (DON) revealed that staff should remove gloves and perform hand hygiene prior to touching anything else in the room to avoid spreading infection. On 04/02/25 at 10:12 AM, the Infection Preventionist (LPN #1) revealed staff should remove gloves to prevent the spread of infection to other surfaces, especially when contaminated with stool. Record review of the Admission Record revealed Resident #44 was admitted on [DATE] with diagnoses that included Hypertensive heart disease without heart failure. Record review of the MDS with an ARD of 2/24/25, Section H, revealed that Resident #44 is always incontinent of bowels.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure proper handling of personal belongings for one (1) of seven (7) residents reviewed for personal property, Resident #49. Findings include: Record review of the facility policy titled Resident Rights, with a revision date of 03/2024, stated residents have the right to . 11. Receive adequate and appropriate . support services . On 03/30/25 at 1:09 PM, during an interview, Resident #49 stated he had a pair of jeans missing. He said his son had recently purchased them and that he had only worn them once. He reported notifying staff, who stated they would look for the jeans; however, he said no one followed up or informed him of the outcome. On 03/31/25 at 4:13 PM, during an interview, the facility Social Services (SS) staff stated she handles admissions and resident concerns. She explained that when a resident reports a missing item, she searches for it, checks with laundry, and if the item cannot be located or is damaged, a grievance is filed, and the facility replaces the item. On 04/01/25 at 7:48 AM, Resident #49 again stated he had reported the missing jeans to SS, but no one had followed up with him regarding the item. On 04/01/25 at 10:51 AM, during a phone interview, the Resident Representative (RR) stated he had purchased two pairs of [NAME] jeans for the resident and was made aware of the missing pair by Resident #49. He said he had spoken with staff and the laundry department but had not received any follow-up. He reported this occurred around the end of February 2025. On 04/01/25 at 2:19 PM, Licensed Practical Nurse (LPN) #2 stated Resident #49 regularly received clothing from his son and should have had an inventory sheet in his paper chart. On 04/02/25 at 9:48 AM, SS staff stated Resident #49 never reported missing jeans to her. She added that she had been on medical leave from 01/02/25 to 02/03/25 and had not been informed about the issue. She stated she could not locate the resident's inventory sheet but had completed one on 04/01/25 following State Agency (SA) request. On 04/02/25 at 3:00 PM, during an interview, the Nursing Home Administrator (NHA) confirmed he was unaware of the missing jeans until recently and had ordered a replacement that day. Record review of Resident #49's Admission Record revealed an admitted [DATE] with diagnoses including Major Depressive Disorder, recurrent, mild. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 01/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was cognitively intact. Record review of the facility grievance log revealed no grievance was filed regarding Resident #49's missing personal item. Record review of the Resident #49's Personal Clothing and Articles Inventory List revealed the sheet was completed on 04/01/25, after the State Agency requested documentation.

Based on observation, interview, record review, and policy review, the facility failed to follow the comprehensive care plan for related to Enhanced Barrier Precautions one (1) of seventeen (17) sampled residents, Resident #5. Findings include: Record review of the facility's care plan policy Care Plan Process dated 12/24 revealed, .The overall care plan should be oriented towards:1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end-of-life situation). 2. Managing risk factors to the extent possible or indicating the limits of such interventions. 3. Addressing ways to try to preserve and build upon resident strengths. 4. Applying current standards of practice in the care planning process . Record review of the Resident #5's care plan with an initiation date of 1/27/25 revealed Focus: The resident has a STAGE 2 pressure ulcer .Interventions .Enhanced Barrier Precautions were in place . On 04/01/25 at 10:18 AM, Resident #5 was observed during wound care to the sacral area. Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #2 were present and providing the care. Neither staff member was wearing gowns nor following Enhanced Barrier Precaution protocols as indicated in the Resident #5's care plan. On 04/02/25 at 10:13 AM, the Director of Nursing (DON) stated that care plans must be followed to ensure safe and appropriate care tailored to each resident's condition. She verified the care plan was not followed in this case and emphasized that failure to use Personal Protective Equipment (PPE) as directed could lead to infection. She emphasized that it is her expectation that staff follow care plans for all residents. On 04/02/25 at 11:41 AM, during an interview, the Infection Preventionist (IP)/ LPN #1, stated that care plans are critical for infection prevention and must be followed. She explained, You can't take care of residents properly without following the care plan. She identified potential outcomes of non-compliance including infection, injury, and residents not receiving needed care. On 04/02/25 at 12:34 PM, the Care Plan Nurse (RN #1) stated care plans are individualized and guide staff in providing appropriate care. She confirmed that failing to follow the plan may result in infection or injury. Record review Admission Record revealed Resident #5 was admitted on [DATE] with diagnoses that included of Schizoaffective disorder. Record review of the Minimum Data Set (MDS)with an Assessment Reference date of 1/8/25 Section C, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Section M documented a Stage 2 pressure injury.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent (5%) for three (3) of four (4) medication administrations observed that affected Resident #1, Resident #39, and Resident #50. The medication error rate was 12.9%. Findings include: Record review of the facility's policy titled, Drug Administration and Documentation, with a revision date of 03/25, revealed, Obtain for the administration and check the order with resident's Medication Administration Record (MAR). Read the medication label and compare it with MAR. Remembering the five rights .Right Dose . Record review of the facility's policy titled, Administering Medications Through Nasogastric or Gastrostomy Tube, with a revision date of 03/18, revealed, Upon the order of the attending physician, medication will be administered through nasogastric/gastrostomy tube when a patient is unable to swallow medications or has a nasogastric/gastrostomy tube for nourishment .7. Flush feeding tube with at least 5 cc (cubic centimeters) of water between medications . Resident #50 On 04/01/25 at 8:07 AM, during an observation of medication administration for Resident #50 by Licensed Practical Nurse (LPN) #4, the resident was administered two puffs of Albuterol Sulfate Inhalation by mouth. LPN#4 waited one minute and then gave oral pills with water. LPN #4 then administered one puff of Advair HFA Inhalation Aerosol 45-21 MCG/ACT (milligrams/actuated) (Fluticasone-Salmeterol) but did not rinse the resident's mouth afterward. Record review of Resident #50's Order Summary Report revealed an order dated 8/16/24 for Albuterol Sulfate HFA Inhalation Aerosol 108 (90 Base) MCG/ACT 16-24 two puff inhale orally two times a day related to COPD, by mouth twice a day. An additional order dated 12/9/24 for Advair HFA Inhalation Aerosol 45-21 MCG/ACT (Fluticasone-Salmeterol) one puff by mouth twice a day. Offer resident to rinse mouth after use. Record review of Resident #50's Admission Record revealed an admitted [DATE]/16/24 with diagnoses that included Chronic obstructive pulmonary disease (COPD). Record review of Resident #50's Minimum Data Set (MDS) with an Assessment Reference Date ( ARD) of 02/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #39 On 04/01/25 at 8:20 AM, during observation of medication administration for Resident #39, LPN #2 instilled two drops of Blink Tears Ophthalmic Solution 0.25% (Polyethylene Glycol 400 Ophth) in each eye, instead of one drop per eye as ordered. On 04/01/25 at 10:12 AM, during an interview, LPN #2 confirmed she administered two drops in each eye and acknowledged the order was for one drop in each. She confirmed that she did not follow the physician's order. Record review of Resident #39's Admission Record revealed an admitted [DATE] with diagnoses that included of rash and other nonspecific skin eruptions. Record review of Resident #39's Physician Orders revealed: Blink Tears Ophthalmic Solution 0.25%:Instill one drop in both eyes as needed every 6 hours for dry eyes. Order date 1/27/25. Record review of Resident #39's MDS with ARD 03/04/25 revealed a BIMS score of 15, indicating cognitively intact. Resident #1 On 04/01/25 at 8:38 AM, during observation of medication pass for Resident #1 via Percutaneous Endoscopic Gastrostomy (PEG) tube, LPN #4 administered multiple medications without flushing the tube with 5 cc of water between medications. Record review of Resident #1's Order Summary Report included orders with a start date of 4/1/25 for Eliquis 5 mg: Give one tablet via PEG tube twice a day. Famotidine 40 mg: Give one tablet via PEG tube twice a day. Fluoxetine 10 mg: One tablet daily via PEG tube. Metoprolol 25 mg: One tablet via PEG tube twice a day. Glycolax (MiraLAX) 17 grams via PEG tube once daily. Record review of Resident #1's MDS with an ARD of 03/10/24 revealed a BIMS score of 08, indicating moderate cognitive impairment. Record review of Resident #1's Face Sheet revealed an admitted [DATE] with diagnoses including Cerebral palsy. On 04/01/25 at 10:18 AM, during an interview, LPN #4 confirmed she did not wait 5 minutes after administering Albuterol Sulfate before proceeding with oral medications. She also confirmed she did not offer Resident #50 water to rinse the mouth after the Advair inhaler. She acknowledged administering two puffs of Advair instead of one as ordered. LPN #4 further confirmed that she did not flush the PEG tube with 5 cc of water between medications. She stated the purpose of mouth rinsing after inhaler use is to prevent oral thrush, and the purpose of flushing the tube between medications is to prevent clogging and ensure the resident receives the full dosage. On 04/02/25 at 11:22 AM, during an interview, the Director of Nursing (DON) stated that LPN #2 and LPN #4 should have followed physician orders. She stated Resident #50 should have been asked to rinse and spit after using the Advair inhaler. She confirmed the PEG tube should have been flushed with 5 cc of water between medications. She explained that failure to rinse the mouth after inhalers can cause oral thrush, and not flushing the PEG tube can lead to clogging and medication mixing. She emphasized that not following physician orders can cause adverse reactions and that it is her expectation that nurses administer medications accurately and per orders.

Based on observation, interviews and facility policy review the facility failed to remove expired foods from the dry food storage area for one (1) of four (4) kitchen observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: Review of the facility's policy, Food Storage Labeling, with a revision date of ,d+[DATE], revealed, POLICY: The facility will ensure the safety and quality of foods by following good storage and labeling procedures. PROCEDURE: . 8 . iv. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturers use-by date or expiration date. Suggested Time frames: 1. Dry Storage - Weekly . On [DATE] at 9:50 AM, during the initial tour of the kitchen with the Dietary Manager (DM), observation of the dry goods storage area revealed the following: a. (1)- 10-ounce bottle of A-1 Original Steak Sauce(R) with an expiration date of [DATE], without an open date. b. (1) quart Classic Imitation Vanilla Flavor, with an open date of ,d+[DATE] and no expiration date c. Two (2)- 16 ounce bottles of yellow food color, without open or expiration or open dates d. (2)- 24 ounce bottles of Hershey's Syrup(R), with an expiration date of ,d+[DATE] e. 4.5 pounds of Minors Sweet and Sour Sauce(R) ready to use sauce, with an expiration date of [DATE], without an open date. On [DATE] at 10:25 AM, during an interview, the DM revealed expired foods should be removed from the storage room on the date of expiration. She stated expired foods are not safe for residents to eat, as they could get sick from eating expired foods. The DM confirmed it is her responsibility to discard expired food. On [DATE] at 11:09 AM, in an interview with the Administrator, he stated that he expects the dietary staff to promptly remove expired foods and to follow food storage protocol.

Based on interviews, record review and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the facility failed to ensure payroll-based journal (PBJ) direct care staffing information was submitted accurately to the Centers for Medicare and Medicaid Services (CMS) for nine (9) of nine (9) months reviewed. Findings include: On 01/29/24 at 11:27 AM, during an interview with the Licensed Practical Nurse (LPN) #1 who is the Infection Preventionist (IP) and Staffing Coordinator, she stated that she is responsible for scheduling Certified Nurse Aides (CNAs) and nurses. She explained some of the nurses are on a Baylor schedule which means they work 16-hour shifts on weekends. LPN #2 and LPN #3 are LPNs that work the Baylor schedule. She reported that the facility's Administrative Aide (AA) enters the PBJ information. An interview on 01/30/24 at 11:34 AM, with the AA revealed the AA enters the staffing hours using the employee's punches to a spreadsheet and those numbers are maintained by the corporate office. During an interview on 01/30/24 at 3:30 PM, the Administrator reviewed the PBJ audit report and stated there was a glitch in the system and prior to reviewing the audit report, he was not aware that there were errors in reporting. The Administrator confirmed that he has access to the reporting system, can run audit reports as needed, and was responsible for checking the reports for accuracy. He confirmed that LPNs #2 and #3, which are on the Baylor schedule, are classified in the PBJ data as Registered Nurses (RNs) and not LPNs, which makes the PBJ information submitted to CMS inaccurate. A record review of the PBJ Audit report provided by the facility revealed LPNs #2 and #3 have hours entered each month from January 2023 through September 2023 as RNs and not LPNs.

Based on interviews, record review and facility policy review, the facility failed to provide the Resident and/or the Resident's Representative with written notification for the reason the resident was transferred to a local hospital for one (1) of one (1) record reviewed for hospitalization . Resident #39 Findings include: Record review revealed the facility provided a copy of the bed hold policy instead of the transfer policy. Record review of the Physician's Telephone Order, dated 12/12/23 at 8:31 AM revealed Send to ER (emergency room ) for evaluation 12/12/2023. Review of a transfer letter, for Resident #39, dated 12/12/23 revealed, This letter is to inform you of the facility initiated transfer/discharge to (Name of local hospital) on 12/12/23 due to an emergency situation for the following reasons(s): We are no longer able to meet your needs in this facility and the transfer is necessary for your welfare. Record review of the Face Sheet for Resident #39 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Anemia in Chronic Kidney Disease, End stage Renal disease, Peripheral Vascular Disease, Raynaud's Syndrome with Gangrene, and Peripheral Vascular Disease. Record review of the Minimum Data Set (MDS) for Resident #39, with an Assessment Reference Date (ARD) of 12/12/23 revealed a discharge assessment, with return anticipated. On 01/31/24 at 11:09 AM, in an interview with Licensed Practical Nurse (LPN) #2, stated resident is on dialysis and has been hospitalized several times related to dialysis. She stated he was hospitalized for low hemoglobin and hematocrit, low potassium, and his fingers eventually had to be amputated related to Raynaud's. On 01/31/24 at 2:55 PM, in an interview with the Director of Nurses (DON), she stated that when a resident is transferred to the hospital for 24 hours, Social Service fills out the transfer letter and bed hold and sends it to the family. She stated Social Services keeps a copy in a binder in his office. On 01/31/24 at 3:00 PM, in an interview with Social Services, he revealed he fills out the transfer and bed hold letters and the Administrator signs off on the letter and he sends it to the family. He commented he was not aware the form had to include the reason for transfer to the hospital, as he uses the standard transfer form provided by the company.