Every finding on record at Legacy Estate Long Term Care

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of the residents for 1 of 2 medication rooms and 1 (North Hall Med Cart) of 3 medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure six jars of Fleet Rectal Glycerin suppositories (used rectally for constipation) were removed from the refrigerator in the North Hall medication room when they had expired on 05/01/2025.2. The facility failed to ensure 14 Swab Caps (medical single use, plastic disinfecting cap containing a pad saturated with 70% isopropyl alcohol which protects and disinfects needle free IV connectors from bacterial contamination) were removed from the North Hall medication room when they had expired on 12/02/2024. These failures could place residents at risk of not receiving the therapeutic benefit of medications and biologicals used for testing and treatment of residents, and at risk for drug diversion and an increased risk of infection. Findings included: During an observation of the North Hall medication room refrigerator at 10:47 a.m. on 08/25/2026 there were six jars of Fleet Rectal Glycerin suppositories (used rectally for constipation) that were expired on 05/01/2026, 26 vacutainer tubes (tubes used to obtain intravenous blood samples for laboratory testing) with expiration dates ranging from 5/1/25 to 5/31/26, and 14 Swab Caps ( medical single use, plastic disinfecting cap containing a pad saturated with 70% isopropyl alcohol which protects and disinfects needle free IV connectors from bacterial contamination) were removed by staff from the medication room when they had expired on 12/02/2024. During an interview on 08/25/2026 at 10:55 a.m., the DON stated the fleets rectal suppositories, the vacutainer tubes, and the swab caps should have been removed from the medication room when they expired. She stated she was not aware prior to today that those items were expired. She stated the central supply person was responsible for checking the medication room for expired over the counter meds and the nurses and medication aides should always check to see that any supplies that they used were not out of date. She stated the expired suppositories were probably missed because no one thought to check the refrigerator for over-the-counter supplies. She stated the expiration dates on the vacutainer blood collection were only occasionally used by staff to obtain blood samples when a physician ordered a lab test on a resident that needed to be drawn before the next scheduled lab day. She stated that since the items were not being used routinely , it may have led to no one noticing the items needed to be removed and replaced. She stated her expectation was that expired medications and supplies were discarded immediately. The DON stated the result of using expired supplies and medications could be that a resident would not receive the intended therapeutic effect, or inaccurate lab results. During an interview on 08/25/2026 at 11:10 a.m. MA F stated at . using medications after expiration could cause unintended reactions to occur in a resident. She stated she was not sure what using an expired vacutainer tube to collect a blood sample could do, but if it were expired it just made sense it should be discarded and not used on a resident. She stated she did not know of any resident that had experienced a negative effect from expired medication or supplies. She stated all nurses and medication aides should check supplies for expiration dates until using them. During an interview on 08/25/2026 at 4:32 p.m. Central Supply clerk Gstated she did Medical Records, Pharmacy Tech and took care of Central Supply at the facility. She stated she went in to the medication room with a nurse when she reordered supplies. She stated she was responsible for making sure the supplies including the supplies in the refrigerator of the med rooms were not expired. She stated she had not been asked to reorder the medications in the refrigerator before, or she would have looked at the expiration dates. She stated in the future, she would look for expirations on the lab equipment, swab kits, and medications in the refrigerator. She stated the nurses would write on a white board what medications needed to refilled so that she would know to refill them, but she had not been asked to refill the suppositories and enemas as they must not be used frequently. Record review of the facility's policy titled House Supplies/Floor Stock Medication and Supplies dated 10/2023: A list of non-prescription house supply/stock medications will be prepared by the facility which may include, but not be limited to analgesics, antacids. antihistamines. Decongestants, Laxatives and stool softeners, vitamins, topical lubricants, and test reagents. Stock medication must be ordered by the director of nursing or designee from the pharmacy or alternate approved prescribers. Containers must contain the name and strengths of medications, manufacturer, lot number, expiration date and usual adult dose or directions of use.

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 for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure foods were labeled properly in the kitchen.The facility failed to ensure open packages were sealed and dated. These failures could place residents that eat out of the kitchen at risk of food borne illnesses.Findings included: During an observation on 08/23/2026 at 10:00am revealed an open bag waffle shaped fries not sealed, not labeled or dated in the freezer in the kitchen. During an observation on 08/23/2026 at 10:10 am observed in one of 3 refrigerators in the kitchen one clear plastic bag with 3 green onions not labeled and had a use by date 8/13. One plastic container with red cut up food product and label on container that was written: tomatoes use first 8/20. One clear plastic zip bag with half a tomato with no label or date on bag. One clear plastic zip bag with half of a white onion with no label or date on the bag. One package of butter opened with no label or dates on package. One package of what appeared to be cheese was open to air in the refrigerator with no dates or label on the package. One clear container with label use first 8/19 Tartar sauce, no received or open date. During an observation on 08/23/2026 at 10:15 am revealed one clear plastic bag of frozen breaded product with no label, or dates on the bag. During an observation on 08/23/2026 at 10:18 am in the dry storage area revealed one box with manufacturer label lasagna noodle open with no open or use by date. One open clear bag which appeared to be dried noodles with no label, no open date or use by date. During an interview on 08/24/2026 at 09:10 am the Dietician stated her expectations were that all food products in the refrigerators, freezers and dry storage should have been dated with received date, open date if opened and the use by dates. The Dietician stated there could have been a potential for harm to the residents if they served food that had expired or was not stored properly. The Dietician stated she and the ADMN were responsible for checking the food products for labels and dates and proper storage. The Dietician stated she did not know how this failure occurred. The Dietician stated that all dietary staff were trained on how to store food in the kitchen when they were hired. The Dietician stated the staff were trained by the dietary manager or herself. During an interview on 08/24/2026 at 11:00 am [NAME] A stated the food in the refrigerator, freezer and dry storage should have labels with date received, date opened and the date to use by. [NAME] A stated the dietary staff were responsible for making sure the dates were on the food containers. [NAME] A stated she the residents could get sick if they ate food that was not good or was spoiled. [NAME] A stated she did not know why this happened. [NAME] A stated she did not know of any residents getting sick from the food from the kitchen. [NAME] A stated she had been trained to label food when it came in on the truck and when it was opened and when it needed to be used by. During an interview on 08/24/2026 at 11:09 am [NAME] B stated the food products should be labeled with the date received off the truck and have the open date when opened. [NAME] B stated if the food was not dated correctly someone might use the food and the residents could get sick if the food was out of date. [NAME] B stated she did not know why the labels were not on all of the food that was stored. [NAME] B stated all the dietary staff were responsible for putting the labels on the products when it came in on the truck, when it was opened. [NAME] B stated the use by date should be put on the food when the package was opened. [NAME] B stated she had been trained on how and when to label food used in the kitchen. During an interview on 08/25/2026 at 10:43 am the ADMN stated her expectations were that all food products would be labeled and dated. The ADMN stated this could potentially be harmful for the residents being exposed to a food borne illness if they consumed food that was out of date or expired. The ADMN stated she and the dietician were responsible for ensuring the food products were labeled properly. The ADMIN stated either she or the Dietician would check periodically for food labels. The ADMIN stated they did not have a schedule for checking the food labels. Record review of the facility's policy titled: Daily Storage Procedures, dated (02/2025) revealed:Purpose:To maintain high quality foods by proper food storage.Environment and equipment requirementRefrigeration and freezers that maintain appropriate temperatures will be provided. Food StorageA. Food should be storedIn a clean, dry secured locationContainers with unpackaged food items will be sealed tightly and include date of openB. LabelingAll food items will be labeled as to contents, particularly those items that have been removed from their original packages (for example cooking oils, flout, salt, sugar.Opened food items shall be carefully resealed and dated as to the date of opening and expiration date and placed into a zip lock storage bag and stored in the tote with other unopened product of the same type.All items will be labeled with a received date. If items are removed from boxes and placed into a storage container, and expiration date will also need to be added to the label.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 6 (Resident #87) residents observed for oxygen management. The facility failed to post a no smoking oxygen in use sign indicating Resident #87 received oxygen on 08/23/2026, 08/24/2026, and 08/25/2026.This failure could place residents at risk of receiving incorrect or inadequate oxygen support; decline in health; and at risk of fire hazards.Findings Included:Record review of Resident #87's electronic face sheet dated 08/25/2026 reflected an [AGE] year-old female who admitted on [DATE] and re-admitted on [DATE] with diagnosis of COPD (chronic respiratory disease that obstructs the airways and interferes with breathing).Record review of Resident #87's entry MDS, dated [DATE], reflected she was admitted on [DATE] from home. Record review of Resident #87's baseline care plan, dated 08/16/2026, reflected Resident #87 used oxygen therapy while a resident. Record review of Resident #87's electronic physician orders, reflected an order for oxygen at 2 L/min every shift via nasal cannula with a start date of 08/15/2026. During an observation and interview on 08/23/2026 at 10:22 a.m., Resident #87 was sitting in the restroom in her room brushing her hair. She stated she had been on oxygen since she had been re-admitted into the facility. Her oxygen concentrator was on and set to 2 L/min. There was no date on the oxygen tubing. She stated she had no concerns with how she was treated in the facility. There was no oxygen in use sign posted outside Resident #87's room. During an observation on 08/24/2026 at 9:10 a.m., Resident #87's room did not have the no smoking oxygen in use sign posted outside of it.During an observation and interview on 08/25/2026 at 09:23 a.m., Resident #87 was sitting on the side of her bed in her room. The oxygen concentrator was on and set to 2 L/min. Oxygen was being administered to Resident #87 via a nasal cannula (tubing that goes into the nose). There was no date on the oxygen tubing. There was no oxygen in use sign posted outside of Resident #87's room.During an interview on 08/25/2026 at 9:22 a.m., RN D stated she was the nurse responsible for the hall Resident #87 resided on. She stated the nurse who put in the oxygen order was responsible for telling a CNA to put up the no smoking oxygen in use sign or put up the oxygen in use sign themselves. She stated she did not know why Resident #87 did not have the oxygen in use sign outside of her door. She stated she would go and find a no smoking oxygen in use sign to put outside of her room on the door trim. During an interview on 08/25/2026 at 9:24 a.m., the DON stated she expected for a no smoking oxygen in use sign to be posted outside of the room if a resident used oxygen. She stated the facility was a non-smoking facility, so she did not feel there would be any negative impact to the resident from the sign not being posted other than the facility being deficient of the regulation. She stated if the electricity went off, the oxygen concentrator would already be plugged into the generator outlet so the oxygen concentrator would continue to run. The DON stated the ADONs were who monitored the oxygen in use signs were posted.During an interview on 08/25/2026 at 9:36 a.m., ADON C stated she was unsure why Resident #87 did not have a no smoking oxygen in use sign outside of her room on 08/23/2026 until the morning of 08/25/2026. She stated Resident #87 was the facility's most recent admission and she was admitted on the weekend. ADON C stated she was responsible for putting out the sign and just missed putting the sign up. She stated if the oxygen in use sign was not posted, it could cause harm because staff may not know to provide her with non-flammable lip balm or not know to make sure the oxygen was changed to a canister when Resident #87 left the room. During an observation and interview on 08/25/2026 at 4:18 p.m., the electricity was off in the facility, and the generator did not start. Many staff observed on the halls making sure that residents with oxygen being administered had a canister to administer oxygen as the concentrators were not getting any electricity. The DON was one of the staff on the halls making sure all residents were taken care of. During an interview on 08/25/2026 at 4:48 p.m., the DON stated if the generator did not come on during a power outage, the oxygen in use sign would help staff identify which residents would need to have the oxygen concentrator changed to the oxygen canisters. She stated the staff knew Resident #87, and she did not think the staff would have missed connecting Resident #87's nasal cannula from the oxygen concentrator to the oxygen canister. Record review of facility policy, titled Oxygen Administration, dated 08/2023, reflected The administration, monitoring of responses and safety precautions associated with it are performed by the nurse.11. Place NO SMOKING signs in area where oxygen is administered and stored. Store oxygen cannisters in an area free of flammable substances.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident # 51) of 4 Based residents reviewed for medications. The facility failed to administer Resident #51's Klor - con (medication used to supplement potassium) as recommended by the manufacturer and dispensing pharmacy on 08/25/2026. The failure placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Review of Resident #51's electronic face sheet dated 08/25/2026 revealed: resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, high blood pressure, diabetes, and lack of coordination. Review of Resident # 51's MDS dated [DATE] revealed a BIMS score of 08 which indicated moderate cognitive impairment. Review of the MDS dated [DATE] also revealed Section K Swallowing/Nutritional Status: Swallowing Disorder: None of the above which indicated no swallowing issues. Review of Resident #51' comprehensive care plan last revised 06/30/2026 revealed no evidence of crushing or mixing medications or of difficulty with swallowing. Review of Resident #51's electronic physicians orders dated 08/24/2026 revealed May alter medications by crushing, opening caps, or administration in food or fluids (Only open or crush medications if manufacture allows) and Klor- con 20 M tablet extended release Give 1 tablet by mouth one time a day DO Not Crush, may dissolve in liquid, furosemide 20 mg give one tablet by mouth in the morning, diltiazem give one tablet 2 time a day in the morning and in the evening, thermos tab give one table in the morning and in the evening, Tylenol extra strength 500 mg tablet give 1 tablet two times a day, and Buspar 10 mg give 1 tablet three times a day. During an observation on 8/24/2026 at 8:50 AM, MA F prepared Resident #51's medications for administration. She placed Klor- con 20 M tablet extended release, furosemide 20 mg ng, diltiazem, a thermos tab, Tylenol extra strength 500 mg tablet, and Buspar 10 mg. She crushed the medications together and administered them to the resident with a spoonful of chocolate pudding. She offered Resident #51 an 8 oz glass of water after she took the medication to swallow the pills, she did not instruct the resident to drink all of the water. During an interview on 08/25/2026 at 4:48 p.m. the DON stated the facility does not crush any medication that was extended release, enteric coated, or has an order not to crush. She stated the Klor-con for Resident #51 should not have been crushed. She stated she was unaware why the Klor - Con was crushed. She stated the pharmacist came to the building once a month and supervised the nurses and medication aides administered medications as directed. She stated the pharmacist consultant would pick one staff member to watch medication administration. She did not know the last time MA A was observed by the pharmacist. She stated she had not been concerned about how she passed medications because she had worked at the facility for a while. She stated potassium should not be crushed because it was an extended release and it could cause the medication to be released faster. She stated she expected the nurse to look at the order and if the order stated do not crush the medication should not be crushed. During an interview on 08/25/2026 at 4:55 p.m. with MA F she stated she administered Resident #51 her potassium this morning and it was crushed. She stated she crushed the medication because the resident requires crushed meds and takes it in pudding, the potassium will not dissolve in pudding. She stated she did not see the do not crush notation on the medication order. She stated she would not crush the potassium anymore. She stated a negative outcome of the resident having the potassium crushed could be the resident not getting enough of the medication. She stated she would call the physician and request a liquid form of the medication. Review of facility policy titled Oral Medications That Should Not Be Crushed, dated revised 08/05/2026 contained the following in part: The following table contains drugs available in the US or Canada that have characteristics that may make it inappropriate to pressure alter the dosage form to help facilitate drug delivery there are a variety of reasons for crushing tablets or capsule content prior to administering divination patients may have internal feeding tubes which do not permit the administration of old tablets or capsules and oral solution for a particular medication may not be available from the manufacturer are readily prepared by pharmacy patients may have difficulty swallowing capsules or tablets or mixing of powdered medications with food or drink may make the drug more palatable generally medications which should not be pressed fall into one of the following categories extended release products, medications which are irritating to the stomach, foul tasting medication, sublingual medication, and effervescent tablets. Klor-con is an extended-release medication that should not be crushed. Review of information on http: Drugs.com revealed the following in part: Do not crush to break or suck on an extended-release tablet or capsule such as Klor-con. Swallow the pill whole breaking or crushing the pill may cause too much of the drug to be released at one time. Sucking on a potassium tablet can irritate your mouth or throat take Klor-con with food or just after a meal. Take the Klor-con with a full glass of water.

Based on observation, interview, and record review, the facility failed to store medications in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of three med carts (North Hall Med Cart) The facility failed to keep each resident's drugs in their original containers/packaging. This failure could place all residents at risk for decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions. Findings included: During an observation on 08/25/2026 at 11:15 AM, the North Hall medication cart had four loose pills and tiny pieces of foil back paper in the second drawer of the medication cart. The pills and paper were laying loose under the blister packages of resident medications. During an interview on 08/25/2026 at 11:20 AM, MA E stated she was unable to identify the loose pills in the bottom second drawer of the North Hall medication cart. MA E stated there should not be pills loose in the medication cart. MA E stated this was her cart and she had not had a chance to look through the cart this morning. MA E stated that staff sometimes got in a hurry and would accidentally drop pills that fall into the drawer of the medication cart. She stated sometimes they just pop another pill out of the blister pack and then forget to go back and dispose of the pill that was dropped in the bottom of the drawer. MA E she could not think of a negative outcome for the resident other than a resident could be delayed on receiving their medications, or the pharmacy might not want to refill a medication if they ran out too early. MA E stated that all staff were responsible for ensuring their medication carts were clean, organized and free from any loose pills. During an interview on 08/25/2026 at 11:25 am with the DON, she stated her expectation was that pills should not have been loose in the bottom of the medication cart. The DON stated the night shift were responsible to check medication carts once per week and staff that use the cart should also be aware and be checking each shift. The DON stated the negative effect on residents would be that they could have run out of medication sooner than they should have and puts residents at the potential for having medication missed. The DON stated the reason for the failure was staff were not checking and cleaning their carts. Record review of the facility policy titled, Medication Administration dated 08/2023 revealed in part: After the medication administration process is completed the medication cart must be completely locked and stored in a locked medication room or otherwise secure the medication, the medication cart and surrounding work area must be clean at all times.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed.The facility failed to ensure foods were labeled properly in the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.The findings included:During an observation and interview on 06.29.2025 between 01:25 PM and 4:15 PM AM of the kitchen revealed:Refrigerator #1 1. Refrigerator contained one pitcher of lemonade (approximately 100 mL) with a use by date 06.28.25 Dry storage1. 1 large clear plastic bag with what appeared to be coconut flakes, sealed with no label or use by date.2. 1 5-pound bag of graham cracker crumbs, marked as received date 05.31.2025, opened 06.03.2025 and no use by date.3. 1 opened package peanut granules with no use by date4. 1 small clear plastic bag with vanilla wafers with no open or use by date5. 1 large storage bin of cornmeal on the floor with wheels, no label or date. 6. 1 16-ounce container of beef base, opened with no expiration date.Freezer #1 1. 1 package of prepared dinner rolls with no label or use by date. Freezer #2 1. 1 tub opened beef taco filling with no use by date2. 1 package of six prepared of a brown, small, loaf sized product. No label or use by date.Freezer #3 1. 1 package of 8 taquitos stored in clear plastic bag with no label or use by date2. 1 package California blend vegetables with no use by date. Refrigerator #4 3. Shredded lettuce in a clear plastic bag with no label or used by date4. 1 large clear plastic bag of carrot sticks with no label or used by date.During an interview on 06/29/2025 at 01:45 PM, [NAME] B stated when the truck delivered the groceries, the staff labeled and dated products with the date received. [NAME] B stated whoever put up the food was supposed to write the date received on the products. T [NAME] B stated when a container was opened, it should have an open date on the container or the bag. [NAME] B stated sometimes the date were rubbed off when stored in the refrigerator or freezer. [NAME] B stated she did not know how the failure occurred. [NAME] B stated if food was passed its use by date and was served to the residents, it could have caused them to get sick. During an interview on 07/01/25 at 02:16 PM, the DM stated food products should have been labeled with the date it was received. The DM stated prepared food products should have been labeled with a preparation date and use by date. The DM stated if food was not labeled and was out of date and served to residents, it could have caused food borne illness. The DM stated all the kitchen staff were responsible for labeling and dating food products. The DM stated all dietary staff were trained when they were hired on labeling and storing food products. During an interview on 07/01/25 at 02:30 PM, the ADMN stated her expectations would be that the kitchen staff would follow the policy for storage and labeling of food products. The ADMN stated food products should be properly labeled and dated. The ADMN stated if outdated food was served to the residents, they could become ill. The ADMN stated that the Dietician provided her with a report each month. The ADMN stated she randomly checks food products in the kitchen about two times a month. The ADMN stated she believed the system works, but maybe some of the products got overlooked. The ADMN stated she did not know what caused the failure. Record review of facility's policy titled: Food Storage dated 2013Policy:Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.Procedure:1. Dry storage must be well ventilated .2. Storage rooms must have only one access door .3. Food items will be stored on shelves, with heavier and bulkier items stored on lower shelves4. All containers must be legible and accurately labeled and dated.6.5. Scoops .7.6. 8.7. All stock must be rotated with each new order received a. Food should be dated as it is placed on the shelves.d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high-risk food.e. Foods will be stored and handled to maintain the integrity of the packaging until ready for use 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.14. Refrigerated Food storage: .All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe u se by dates, or frozen (where applicable), or discarded.Refrigerated foods should be stored upon delivery .Frozen Foods:All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS , for 1 of 1 (FY Quarter 2 2025) reviewed for Staffing Data Report.The facility failed to submit staffing information to CMS for FY Quarter 2 2025 (January 1- March 31).The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS , for 1 of 1 (FY Quarter 2 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 2 2025 (January 1- March 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's Staffing Data Report for FY Quarter 2 2025(January 1- March 31) revealed the facility triggered for Failed to Submit Data for the Quarter. During an interview on 07/01/2025 at 2:17 PM, the ADMN stated her expectation was that the facility followed CMS guidelines. The ADMN stated it was oversight on her part, with trying to get everything completed for opening a new building. The ADMN stated she had looked several times and the links for reporting data were not available and she must have missed the time frame when the links for reporting had opened. The ADMN stated it was her responsibility to ensure the staffing data was reported. The ADMN stated she did not feel there was a negative effect to residents. The ADMN stated the facility did not have a policy for reporting staffing data, they followed the CMS guidelines.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Residents #23, and Resident #27) reviewed for care plans in that:The facility failed to ensure Resident #23 had a care plan in place for pressure ulcer/injury.The facility failed to ensure Resident #27 had a care plan in place for urinary incontinence.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Residents #23, and Resident #27) reviewed for care plans in that:The facility failed to ensure Resident #23 had a care plan in place for pressure ulcer/injury.The facility failed to ensure Resident #27 had a care plan in place for urinary incontinence.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included the following:Review of Resident #23's Resident Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of dementia, diabetes type 2 (a condition when the body does not produce enough insulin or cells do not response properly to insulin), anxiety, depression, high blood pressure, heart failure, chronic kidney disease, Parkinson's disease (a neurological problem that affects movement), and weakness. Review of Resident #23's Annual MDS Assessment, dated 04/04/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #23 scored 15 out of 15 indicating intact cognition. Section M - Skin Conditions, subsection M0150. Risk of Pressure Ulcers/Injuries; Is this resident at risk of developing pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Subsection M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? reflected a zero (0) indicating No was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 16. Pressure Ulcer column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 16. applied.Review of Resident #23's Care Area Assessment Worksheet dated 04/08/2025, Item 16. Pressure Ulcer/Injury under Care Plan Considerations; Will Pressure Ulcer/Injury - Functional Status be addressed in the care plan? Yes was entered. Review of Resident #23's Comprehensive Care Plan reviewed/revised 04/08/2025 revealed it did not address pressure ulcer/injury as a focus of care. Review of Resident #23's physician's order, dated 04/21/2025, revealed Apply skin prep to left heel every day shift.Review of Resident #27's Resident Face Sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of difficulty chewing/swallowing, urinary tract infection, weakness, history of blood clots in the lungs, and iron deficiency anemia (low iron in the blood). Review of Resident #27's admission MDS Assessment, dated 01/17/2025, Section C - Cognitive Patterns, subsection C0500 BIMS Score Summary revealed Resident #27 scored 11 out of 15 indicating moderate cognitive impairment. Section H - Bladder and Bowel, subsection H0300. Urinary Continence revealed 3. Always incontinent (no episodes of continent voiding) was entered. Section V - Care Area Assessment (CAA) Summary, subsection A. CAA Results revealed Item 06. Urinary Incontinence and Indwelling Catheter column A. Care Area Triggered was checked and column B. Care Planning Decision was checked indicating Item 06. applied.Record review of Resident #27's Care Area Assessment Worksheet dated 01/21/2025, Item 6. Urinary Incontinence and Indwelling Catheter under Care Plan Considerations; Will Urinary Incontinence and Indwelling Catheter - Functional Status be addressed in the care plan? Yes was entered. Record review of Resident #27's Comprehensive Care Plan reviewed/revised 04/29/2025 revealed it did not address urinary incontinence as a focus of care. During an interview on 07/01/25 at 01:46 PM, the DON stated the MDS Coordinator, LVN D, was responsible for starting the care plans. She stated she was responsible for monitoring for accuracy. The DON stated all nurses could contribute to the care plan, but she must be notified prior to adding to or changing a care plan. She stated care plans were reviewed by the IDT during quarterly meetings. The DON stated they try to read the entire care plan to identify adjustments that were needed. LVN D stated she had been doing MDSs and care plans for 9 years. She stated she, LVN D received 30 days of training prior to assuming the position. The DON stated the MDS Coordinator was required to complete training periodically offered by the online vendor. The DON stated her expectations were for care plans to be as complete and accurate as possible at all times.During a follow up interview on 07/01/25 at 02:11 PM, the DON stated the consequences of an incorrect or incomplete care plan for a resident may be in the area of ADL's. The DON gave an example of the number of staff required for assisting a resident with transfers. She stated if the information was not correct, a resident or staff may be at risk of injury during a transfer. She stated not so much for medication changes because the changes were addressed in the physician's orders. The DON stated one possible reason for the failure to have an accurate care plan may be when a medication order changes. Review of the facility policy titled Comprehensive Care Plans, dated 09/2023, revealed on page 2 If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.