Every finding on record at Lexington Medical Lodge

Based on observations, interviews, 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 and nutrition services .1. The facility failed to seal lids securely on containers in the refrigerator area2. The facility failed to seal bags securely in the walk-in freezer.3. The facility failed to ensure that [NAME] A washed their hands after removing gloves, between tasks and before returning to food preparation tasks putting on new gloves. [SH1.1]These deficient practices could affect residents who received meals or snacks from the kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included:During an observation and interview on 6/21/26 at 9:02 AM [NAME] A stated the Dietary Manager was not at the facility. [NAME] A stated the facility had 1 kitchen and 1 main dining room. An initial walk through the walk-in freezer, reach-in refrigerator, walk-in refrigerator, and dry pantry was conducted and reach-in refrigerator revealed:-1 small plastic cup without a lid, unlabeled, and undate[SH1.1]d, with an unidentified substance inside exposed to the air was on a shelf in the reach-in refrigerator. - a tray with 12 small cups of a dark unidentified liquid, unlabeled, undated and on the same tray with 6 other small cups of a white unidentified liquid, unlabeled and undated on trays in the reach-in refrigerator. - a tray with 30 small cups of various colors of unidentified liquid, unlabeled, undated, and poorly unsecured lids were on a tray in the reach-in refrigerator. An observation on 6/21/2026 at 9:05 AM of the walk-In freezer revealed a 2 gallon transparent plastic storage bag was unsealed and unlabeled with an unidentified item inside. An observation on 6/21/2026 at 9:15 AM revealed[SH2.1] [NAME] A wearing gloves and preparing food. [NAME] A was observed removing gloves and putting a tray of food in the walk-in refrigerator then opening two cans of soup. [NAME] A did not put on new gloves or perform hand hygiene prior to returning to preparing food. During an observation and interview on 6/22/26 at 11:00 AM with the Dietary Manager revealed the facility dietitian comes on a regular basis two to three times a month and reviews therapeutic menus, conducts assessments, care plans, sanitation rounds, and in-services. Dietary Manager stated one of the cooks is in charge when the Dietary Manager is not on-site. During an observation and interview on 6/23/2026 at 9:20 AM the Dietary Manager[SH3.1], stated the importance of washing hands before and after wearing gloves was to control infection. Dietary Manager stated[SH4.1] the last in-service on hand hygiene, dating, labeling, properly sealing food and beverage containers to protect against cross contamination, was in May. During an observation and interview on 6/23/2026 at 9:30 AM with [NAME] A revealed the importance of washing hands before and after wearing gloves is to not to spread infection. [NAME] A stated the last inservice on hand hygiene, dating, labeling, properly sealing food and beverage containers to protect against cross contamination was in May (2026).During an observation and interview on 6/23/2026 at 9:40 AM with Dietary Aide A stated the importance of washing hands before and after wearing gloves to not cross contamination. Dietary Aide A stated the last in-service was in May talked about hygiene, date, labeling, properly sealing containers to protect against cross contamination. During a brief walk through and interview with the Corporate Dietitian and Dietary Manager on 6/23/2026 at 10:00 AM revealed the unsealed and unlabeled two-gallon, transparent plastic storage bag with an unidentified item inside was no longer in the walk-in freezer. [SH5.1]Record review of the facility's policy, titled in the footer as Resident Care Polices, pages IX.8 and IX.8 revealed,Sanitary Conditions:Food is stored, prepared, distributed and served to residents in accordance with professional standards for food service safety.Food in unlabeled or damaged containers shall not be accepted or retained.Hand washing facilities, including hot and cold water, soap in dispenser, and individual paper towels shall always be available in the dietary department.Orientation:It is the responsibility of the dietary services supervisor to orient all new dietary employees to the facility policies and procedures and the dietary policies and procedures.[SH6.1] Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18.FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306[SH7.1].Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #71) of eight residents reviewed for ADL care. The facility failed to provide Resident #71 with timely incontinence care on 06/21/26. This failure could place residents at risk for a skin breakdown and infection.Record review of Resident #71's quarterly MDS assessment, dated 05/30/26, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 08, indicating his mild cognitive status. His diagnoses included cerebrovascular disease (refers to a group of conditions that affect blood flow and the blood vessels in the brain), muscle weakness, lack of coordination, and myelodysplastic syndromes (a group of disorders caused by blood cells that are poorly formed or don't work properly). The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. Record review of Resident #71's care plan initiated 11/21/24 reflected: The resident required assistance with activities of daily living. Intervention was to provide a level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift. Review of Resident #71's Task Record, dated 06/21/26, reflected the resident did not have documentation showing that the resident received incontinence care on the 6:00 AM -8:00 PM shift. An observation and interview on 06/21/26 at 10:30 AM with Resident #71 revealed he was sitting up in the wheelchair in the hallway. He was awake, alert, and oriented, but seemed forgetful. FM #1 then approached and greeted the resident. She stated she wanted the resident to be changed because FM #2 was on the way to come and see the resident for Father's Day. The resident was noted to be wet. FM #1 stated sometimes, she had found the resident wet in the wheelchair. In an observation and interview on 06/21/25 at 10:43 AM with CNA D it was revealed the staff assisting the resident in bed to be changed. During incontinent care, it was revealed the resident's brief was heavily soiled with urine, and the resident pants were wet. No skin issues were noted to the peri area during care. CNA D stated she was assigned to the resident. She stated the resident required assistance with activities of daily living and used a Hoyer to get out of bed. CNA D stated she had gotten the resident up in the wheelchair around 6:45 AM, and that was the time she provided incontinent care to the resident. CNA D stated that the resident should be cleaned timely and well groomed. In an interview on 06/23/26 at 1:25 PM with the DON, she stated the residents were to be checked every 2 hours and if they needed to be changed, the staff had to change them. The DON stated the residents were not to be left soaking wet with urine. She stated even the residents who used a lift for transfers were to be checked every 2 hours and changed in a timely manner. The resident needed to be changed timely to prevent skin breaking down, and the resident remained well groomed. Review of the facility's policy undated and titled incontinence reflected, . The facility will ensure that the resident who is incontinent receives appropriate treatment and services to prevent urinary tract infections and to restore as much more normal bladder function as possible.

Based on observation, interview, and record review, the facility failed to ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #103) reviewed for feeding tube care. The facility did not ensure Resident #103 received water flushes and medication through the feeding tube by gravity flow in accordance with professional standards of practice. LVN B flushed the tube feeding and gave medication by using the plunger to push the mixture instead of by gravity flow.This failure could place residents at risk for aspiration pneumonia, abdominal discomfort, vomiting, and/or metabolic abnormalities.Findings included:Record review of Resident #103's face sheet dated 06/23/2026 revealed Resident #103 was a [AGE] year-old male with admission date of 12/17/2024, diagnoses of Hemiplegia (a severe or complete paralysis of one side of the body, caused by brain damage on the opposite side) and Hemiparesis (partial weakness or reduced control on one side of the body) , Chronic Obstructive Pulmonary Disease( an umbrella term for progressive, long-term lung diseases that cause obstructed airflow and make it difficult to breathe), and respiratory failure ( occurs when your respiratory system cannot adequately supply oxygen to your blood or properly remove carbon dioxide from it).Record review of Resident #103's Physician orders dated 06/22/2026 indicated orders included Isosource 1.5 at 70 cc per hour x 22 hours via g-tube and pump. Flush G/tube with 250cc of water every four hours, head of bed elevated 30 to 45 degree always, check tube placement prior to each feeding, meds and fluids per auscultation (the medical practice of listening to internal body sounds-such as those from the heart, lungs, and intestines-to aid in diagnosis.) and residual every shift. If 100cc hold feeding. Record review of Resident #103's Quarterly MDS dated [DATE] indicated Resident #103 had BIMS score of 10 indicating moderate cognitive impairment, and he had a feeding tube for enteral feedings (delivers specialized liquid nutrition directly into the stomach or small intestine). Record review of Resident #103's care plan revised 4/20/2026 indicated The resident requires a G/tube for adequate nutritional intake with intervention -Discuss with caregivers any concerns about tube feeding potential complications; Monitor/document abdominal pain, distension or tenderness, nausea/vomiting An observation of LVN B on 06/22/2026 at 9:05 AM revealed she flushed Resident #103's G/tube with 60 mL of water by pushing the plunger instead of letting the water flush through the feeding tube by gravity.Observation of LVN B on 06/22/2026 at 9:10 AM revealed she gave Resident #103's medication mixed with 30 mL of water by pushing the plunger instead of letting the medication mixed in water flush through feeding tube by gravity. During an interview with LVN B on 06/22/2026 at 09:10 AM, LVN B confirmed she flushed Resident # 103's feeding tube with 60 mL of water and 30 mL of medication mixed with water by pushing the plunger. LVN B stated she was nervous related to being observed for G/tube medication administration. She stated the risk to the resident for pushing fluid with the plunger was abdominal distension, pain, and aspiration pneumonia.During an interview with the DON on 06/22/2026, she stated that LVN B should have flushed Resident $103's tube feeding by allowing the fluid flow through by gravity per professional standards of practice. The DON stated the risk of pushing fluids with the plunger was issues like abdominal bloating/distension and aspiration Pneumonia (serious lung infection caused by inhaling foreign substances-such as food, liquid, saliva, or stomach contents-into the airways instead of swallowing them). The DON stated nursing staff were in-serviced on G/Tube management annually and during hire.Review of the facility's policy titled Assisted Nutrition/Hydration undated stated The facility will ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration and metabolic abnormalities. Parenteral fluids will be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care, consistent with professional standards of practice, for two of seven residents (Resident #82 and Resident #114) reviewed for quality of care. The facility failed to ensure that Resident #82 and Resident #114's oxygen nasal cannula tubing (a small, lightweight tubing with 2 soft prongs that sit just inside the nostrils to deliver extra oxygen) were bagged in a plastic bag. This failure could place residents receiving respiratory therapy at risk of health-associated infections.Findings included: Record review of Resident #82's's admission Record, dated 06/22/26, reflected he was an [AGE] year-old male, who was originally admitted to the facility on [DATE]. He had diagnoses that included: acute and chronic respiratory failure with hypoxia (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually, causing persistent low oxygen in the blood), acute upper respiratory infection (infection in your breathing system), and pulmonary hypertension (high blood pressure in the blood vessels that carry blood from the heart to lungs). Record review of Resident #82's MDS assessment, dated 05/05/2026, reflected that he was receiving oxygen treatments and respiratory therapy 7 days a week. Resident #82 had a BIMS score of 13 which indicated he was cognitively intact. Record review of Resident #82's Care Plan, dated 06/22/26, reflected he required use of continuous oxygen therapy. Record review of Resident #82's Active Orders as of 06/22/26, reflected an active order for oxygen, continuously via nasal cannula. Record review of Resident #82's Respiratory Therapy Needs Assessment, dated 04/29/26, reflected he required 1-3 L of supplemental oxygen to keep his oxygen saturation above 92%. During an observation and interview of Resident #82 on 06/21/26 at 9:00 AM, Resident #82 was observed in his room sitting in his wheelchair. He reported he did not have shortness of breath. His oxygen saturation was observed to be at 95%, which indicated a normal range (the percentage of hemoglobin in the red blood cells carrying oxygen). Resident #82's oxygen nasal cannula was observed not in use and lying on his bed unbagged. He reported he usually used his oxygen when he was in bed. He reported he finished breakfast and didn't recall how long the tube had been lying on the bed, unbagged. He reported he did not have shortness of breath. Record review of Resident #114's admission Record, dated 06/22/26, reflected she was a [AGE] year-old female, who originally admitted to the facility on [DATE]. Resident #114 had a BIMS score of 15 which indicated she was cognitively intact. She had diagnoses that included: chronic embolism and thrombosis (blood clots that formed in the past and never fully went away or caused long-term blockage in a blood vessel), hypoxemia (low oxygen in the blood), Atrial fibrillation (Afib, upper chambers of the heart beat in a chaotic, irregular way), asthma (airways in the lungs are extra sensitive and can narrow or swell making it harder to breathe), and chronic respiratory failure (a sudden, life-threatening inability to maintain oxygen levels, while chronic respiratory failure develops gradually, causing persistent low oxygen in the blood). Record review of Resident #114's Care Plan, initiated on 10/06/25, reflected Resident #114 had altered respiratory status/difficulty breathing related to chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood) and asthma. Record review of Resident #114's Active Orders as of 06/22/26, reflected an active order for oxygen PRN at 2-4 L/PM via nasal cannula or 5-8 L/PM via mask PRN for SOB. Record review of Resident #114's Respiratory Therapy Needs Assessment, dated 05/08/26, reflected she was at high risk for return to acute status (the person is medically fragile and could easily get sick enough to need hospital-level care again) due to recent illness combined with underlying comorbidities and/or decreased activity. During an observation and interview of Resident #114 on 06/21/26 at 9:15 AM, Resident #114 was observed in her room lying in bed. Her oxygen nasal cannula was observed not in use and lying on the floor unbagged. Resident #114 could not recall when the nasal cannula fell out of her nose and onto the floor. The resident was not sure how long the nasal cannula was on the floor. During an interview with LVN A on 06/21/26 at 9:20 AM, he confirmed he was the charge nurse. He visually confirmed the nasal cannula on Resident # 114's floor. He then confirmed the nasal cannula on Resident #82's bed unbagged. He stated nasal cannula tubing were supposed to be bagged when not in use. He stated the risk of unbagged nasal cannulas when not in use could cause infection, possible respiratory emergency, or shortness of breath. During an interview with the DON of 06/22/26 at 10:30 AM, she stated all nursing staff should ensure oxygen tubing were always in place. She stated oxygen tubing should be stored in a clear bag when not in use. She stated the bags should be changed weekly and as needed. She stated the risk of unbagged nasal cannulas were shortness of breath and infection. She stated staff were trained on oxygen management when hired, and monthly thereafter. During an interview with the DON and Administrator on 06/22/26 at 12:22PM, they stated they did not have a policy related to proper storage of respiratory equipment (such as oxygen tubing/nasal cannulas, nebulizer masks, and nebulizer mouthpieces).

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident#106) of six residents reviewed for pharmacy services.The facility failed to ensure that Resident #106 swallowed his medication before leaving the resident room. This failure could place the residents at risk of medication error, reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes. Findings included:Record review of Resident #106's Quarterly MDS Assessment, dated 03/09/2026, reflected Resident #106 was admitted on [DATE]. He was a [AGE] year-old male and had a BIMS score of 13 which indicated intact cognition. The resident had diagnoses which included Hypertension (a chronic condition where the force of blood against your artery walls is consistently too high), Depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities) and Hemiplegia (the severe or complete paralysis of one entire side of the body (left or right), caused by injury to the brain or spinal cord).Record review of Resident #106's Comprehensive Care Plan, initiated 04/25/2025, reflected no areas indicating he could have medication at bedside or self-medicate.Record review of Resident #106's active physician orders dated: 06/22/2026 reflected no orders indicating he could have medication at bedside or self-medicate.Observation and interview on 06/21/20226 at 9:35AM, during initial pool, revealed 4 white oval pills and 1 white round pill in a medication cup on Resident #106's bedside table. Resident #106 stated CMA A left them for him and that he would take them later.During an interview on 06/21/2026 at 9:40 AM, LVN A revealed CMA A administered Resident #106's morning medication. He stated he always ensured the residents swallowed their medication before leaving the room but couldn't tell why CMA A left medications in a cup for Resident #106. LVN A stated Resident #106 did not have physician orders to self-medicate or have medication at bedside. He stated the risk to the resident was over medicating or missing to take medications or another resident getting the medication. He stated he had been in-serviced on medication administration and medication storage and labelling.During an interview on 06/21/2026 at 10 AM, CMA A stated that Resident #106 asked her to leave the medications on his bedside table. CMA A stated she was supposed to watch the resident take his medication before leaving the room or bring it later to Resident #106 when he was ready to take his medication but failed to do that. CMA A stated the risk was Resident #106 missing the medication or another resident taking the medication. She stated she had been in-serviced on medication administration and medication storage and labelling.During an interview on 06/22/26 at 10:30 AM, the DON stated no medications were expected to be left at bedside, at any time. She stated that the medication aides and nurses were expected to stand and watch residents swallow their medications before exiting the room. The DON stated medication aides and nurses had been in-serviced on medication administration and storage.Record review of the facility's policy titled Drug Security undated reflected the following: The facility will be responsible for medication security, accurate information and medication compliance.Facility had no policy on residents' self-medication administration or leaving medication at bedside.

Based on observation, interview and record review, the facility failed to properly label and store all drugs and biological in accordance with currently accepted professional principles for medications for 1 of 4 medication carts, (400-hall nurse cart) reviewed for pharmacy services.The facility failed to ensure Residents #5, #37, #48, and #117's Insulin Lispro was discarded after the opening date of [DATE] of 28 days in accordance with professional standards of practice from the 400-hall nurse cart. These failures could place the residents at risk of reduced therapeutic effectiveness, unsafe administration, and potential adverse outcomes due to improper storage of medication.Findings included:1. Record review of Resident #5's Quarterly MDS assessment, dated [DATE], reflected he was a [AGE] year-old male re-admitted on [DATE]. His BIMS score was 13, indicating intact cognition. His diagnoses included Diabetes Mellitus (a chronic metabolic disorder characterized by persistently high blood sugar (glucose) levels).A record review of Resident #5's active care plan, initiated [DATE], revealed: The resident had Diabetes Mellitus. Facility Interventions included: Diabetes medication as ordered by doctor, fasting serum blood sugar as ordered by doctor.Record review of Resident #5's active Physician Order, dated [DATE], reflected: Insulin Lispro ( a rapid-acting insulin given at mealtimes), subcutaneous ( under, or beneath, all the layers of the skin) solution pen-injector 200 unit/ml, inject per sliding scale(a reactive dosing method where insulin is administered based on your current blood sugar level rather than predicting meals or basal needs) two times a day related to Type 2 Diabetes (a chronic condition where the body either resists insulin or doesn't produce enough of it, leading to high blood sugar) . 2. Record review of Resident #37's Quarterly MDS assessment, dated [DATE], reflected he was a [AGE] year-old male re-admitted on [DATE]. His BIMS score was 14, indicating intact cognition. His diagnosis included Diabetes Mellitus.A record review of Resident #37's active care plan, initiated [DATE], revealed: The resident had Diabetes Mellitus. Facility Interventions included: Diabetes medication as ordered by doctor, monitor/document s/s of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar).Record review of Resident #37's active Physician Order, dated [DATE], reflected: Insulin Lispro (Human) subcutaneous solution pen-injector 100 unit/ml, inject per sliding scale before meals and at bedtime for Diabetes.3. Record review of Resident #48's Quarterly MDS assessment, dated [DATE], reflected he was an [AGE] year-old male admitted on [DATE]. His BIMS score was 11, indicating moderate cognitive impairment. His diagnosis included Diabetes Mellitus.A record review of Resident #48's active care plan, initiated [DATE], revealed: The resident had Diabetes Mellitus. Facility Interventions included: Diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by doctor.Record review of Resident #37's active Physician Order, dated [DATE], reflected: Insulin Lispro subcutaneous solution pen-injector 100 units/ml, inject per sliding scale two times a day related to type 2 Diabetes.4. Record review of Resident #117's Quarterly MDS assessment, dated [DATE], reflected he was a [AGE] year-old male re-admitted to the facility on [DATE]. His BIMS score was 14, indicating intact cognition. His diagnosis included Diabetes Mellitus.A record review of Resident #117's active care plan, initiated [DATE], revealed: The resident had Diabetes Mellitus. Facility Interventions included: Diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered by doctor, monitor, monitor/document s/s of hyperglycemia and hypoglycemia.Record review of Resident #37's active Physician Order, dated [DATE], reflected: Insulin Lispro subcutaneous solution pen-injector 100 unit/ml, inject per sliding scale before meals and at bedtime related to type 2 Diabetes.An observation on [DATE] at 10:50AM with the ADON of the 400-hall nurse cart revealed Insulin Lispro Solution pen-injectors for Resident #5, Resident #37, Resident #48, and Resident #117 had opening dates of [DATE]. During an interview on [DATE] at 11AM with the ADON, she stated nurses were responsible for ensuring the medications were within date, and all medications that were discontinued were removed from the cart for proper disposal. She stated the risk to the resident was medication error and medication not being effective if it expired. She stated that she had been in-serviced on medication storage. During an interview on [DATE] at 10:30AM with the DON, she stated that it was the responsibility of every nurse to check the label and open date before administering insulin to a resident. The DON stated insulin was supposed to be dated because it expired 28 days after opening. She stated that failure to discard out of date insulin could result in administering medication that was expired and could not be effective or that could have negative side effects to the residents. The DON stated all expired medication, discontinued medication, and medication of discharged residents should immediately be removed from the medication cart. She stated that the ADON audited the medication carts biweekly and as needed, but there was no set schedule. She stated that the pharmacist audited the medication carts monthly. Record review of the facility's policy titled Drug Security undated reflected the following: The facility establishes procedures for storing and disposing of drugs and biologicals in accordance with federal, state and local laws.Medications which have passed the expiration date and medications which have been discontinued will be stored separately under lock and key in the director of nurses' office and in the medication room and be reconciled. These medications will be disposed quarterly by the consulting pharmacists and the director of nursing and or the administrator in accordance with state and federal requirements.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of four residents (Resident #1, Resident #2, and Resident #5) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA B provided appropriate perineal care for Resident #1 when he failed to clean the resident's penis, scrotum, and pubic area on 10/07/25. 2.The facility failed to ensure CNA B provided appropriate catheter and perineal care for Resident #2, who was being treated for a urinary tract infection, when he failed to change the surface of the peri-wipes when cleaning the resident's penis, scrotum, and perineal area, failed to wipe the catheter tubing from the tip of the penis downward and failed to keep the urinary drainage bag below the bladder while providing care on 10/07/25. 3. The facility failed to ensure CNA B and CNA C maintained the urinary catheter drainage bag below Resident #5's bladder while they transferred the resident with a mechanical lift and while providing incontinence care and a bed bath on 10/07/25. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included: 1. Record review of Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 11/27/24. Diagnoses included fracture of left femur, (thigh bone) mild intellectual disability and history of trans ischemic attacks (a brief stroke-like attack resolving within minutes to hours). Record review of Resident #1's 5-day MDS assessment, dated 09/08/25, reflected a BIMS score of 9 which indicated he was moderately cognitively impaired. He was dependent on staff for toileting hygiene and was occasionally incontinent of urine and bowel. Record review of Resident #1's care plan, initiated on 08/11/25, reflected, Resident requires assistance with ADLs.Interventions. Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift.Resident has been identified at risk for pressure ulcer development or skin breakdown.Interventions.Check for incontinence frequently and as needed. Provide incontinence care fer each. In an observation on 10/7/25 at 08:45 a.m. CNA B entered Resident # 1's room and asked the resident if he was ready to get up for therapy and the Resident stated no,. CNA B stated he needed to check to see if he needed changed and the Resident stated OK. CNA B put on gloves and uncovered the resident revealing he had brown rings noted on the bed pad and sheet. CNA B stated this was his first check and change on the resident since he started his 6:00 a.m. shift. CNA B unfasted the resident's brief revealing it was slightly wet. CNA B had the resident roll onto his side and then took a peri-wipe and wiped from the front to the back of the anal area, revealing light brown smears with each wipe. CNA B then pushed the soiled brief down toward the residents' buttocks and rolled the stained sheet under the resident. CNA B changed his gloves but did not perform hand hygiene. He placed a clean sheet, a draw sheet and clean brief under the resident and had him roll to the other side while he pulled the soiled linen out and pulled the clean linen out from under the resident. He had the resident roll back onto his back and fastened the brief without cleaning his pubic area, penial shaft or scrotum. CNA B then unfasted the brief and took a peri-wipe and wiped once down each groin but still did not clean the penial shaft or scrotum. CNA B refastened the brief and straightened the residents covers. In an interview with Resident #1 on 10/07/25 at 08:50 a.m. he stated he was last changed yesterday evening but could not remember the time. He stated they usually come and change him when he calls for them to come and change him. 2. Record review of Resident #2's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 10/04/25. Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and severe sepsis (body's extreme reaction to an infection) Record review of Resident #2's admission MDS assessment reflected it was in process and not complete. Record Review of Resident #2's Order summary report dated 10/07/25 reflected, Catheter care.every shift. Catheter drainage bag to gravity. with a start date of 10/05/25. Record review of Resident #2's care plan dated 10/06/25 reflected, Resident utilizing indwelling urinary catheter placing resident at risk for UTI.Interventions.Provide urinary catheter care per facility protocol every shift and as needed.The resident has a Urinary Tract infection. Interventions.Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. In an observation on 10/07/25 at 09:10 a.m. CNA B entered Resident #2's room, put on gloves, but no gown and told him he was here to get him changed and dressed for therapy. CNA B went to the resident's bathroom to retrieve a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 220 cc of clear yellow urine. CNA B unhooked the urinary catheter drainage bag and laid it on the bed and unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped up the penile shaft up and down with several swipes, using the same wipe and without changing the surface of the wipe. CNA B did not clean the catheter tubing from the tip of the penis downward. CNA B rolled the resident to his side and wiped the anal area from front to back and placed a clean brief under him. CNA B put on clean gloves, with no hand hygiene and applied barrier cream to his buttocks and then rolled the resident over and with the same gloves applied barrier cream to his groin area and penial shaft. CNA B fastened the brief, removed his gloves and put on clean gloves with no hand hygiene and dressed the resident and assisted with transferring him from the bed to the wheelchair. CNA B hooked the urinary drainage bag under the wheelchair. 3. Record review of Resident #5's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 04/20/24. Diagnoses included primary lateral sclerosis (a rare progressive neurodegenerative disease that affects the central motor system in adults), neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired) and adult failure to thrive (a decline in older adults that manifest as a downward spiral of health and ability). Record review of Resident #5's quarterly MDS dated [DATE] reflected the resident had a BIMS of 14 which indicated he was cognitively intact. The resident was dependent on staff for all toileting and transfers, had a foley catheter and was always incontinent of bowel. Record review of Resident #5's Order Summary report dated 10/07/25 reflected, Catheter care.every shift. Catheter drainage bag to gravity. with a start date of 06/20/25. Record review of Resident #5's care plan dated 10/06/25 reflected, Resident utilizing indwelling urinary catheter placing resident at risk for UTI.Interventions.Monitor urinary catheter for proper placement, patency every shift and as needed.Provide urinary catheter care per facility protocol every shift and as needed. In an observation on 10/07/25 at 10:38 a.m. revealed CNA B and CNA C entered Resident #5's room to transfer resident from his recliner to the bed for incontinent care and bed bath. Both staff washed their hands, put on gloves and gowns. CNA B retrieved a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 320 cc of clear yellow urine. Both staff hooked the mechanical lift sling to the lift and CNA C unhooked the urinary catheter drainage bag and laid it on the resident's lap. CNA B instructed CNA C to hang the urinary bag on the lower rung of the mechanical sling, which she did, but as they were raising the lift, Resident #5 pointed towards his feet, and CNA C unhooked the urinary drainage bag and once again placed it on the resident's lap. Urine was observed in the tubing draining back toward the residents body. The resident was transferred from the recliner onto his bed. Both staff rolled the resident side to side to remove the sling and CNA C unfasted the brief and provided catheter care. CNA B then placed the urinary drainage bag onto the bed, and CNA C told him to place it back on the bed rail. CNA B stated no it was fine on the bed. Both staff rolled the resident over on his side revealing he had large soft bowel movement. CNA C wiped from the front to the back, changing wipes with each swipe. CNA C then removed her gloves and put on new gloves without performing hand hygiene and both staff proceeded to provide resident his bed bath with the urinary drainage bag on the bed. In an interview on 10/07/25 at 11:15 a.m. with CNA B when asked about the proper steps for catheter care and incontinence care he stated he was supposed to go from front to back and wipe away from the body down the catheter tube. He stated he realized he had not cleaned Resident #1's front, which is why he opened up his brief, but stated he should have cleaned all of his penis and scrotum. He stated Resident #1 usually used a urinal but stated he did have accidents on occasion. He stated he was not sure if he had spilled the urinal since he was not soaked when he changed him. He stated he was supposed to provide catheter care every time they did incontinence care, and he had failed to do that for Resident #2. He stated he was supposed to wipe once and change the surface of the wipes and did not realize he had not done that. He stated he knew the catheter bag was to remain lower than the bladder but did not think it was an issue placing it on the bed. In an interview with CNA C on 10/07/25 at 11:40 a.m. she stated she knew she was supposed to keep the urinary drainage bag below the resident bladder but stated Resident #5 liked to hold the bag and she did not want to be rude. She stated she knew they were not supposed to lay the urinary drainage bag in the bed because it could not drain laying in the bed and tried to get CNA B to put it on the bed rail. She stated she had only been a CNA for about a year, but stated the facility had skills checked them and the Lead CNA had watched her several times. She stated she was really nervous with someone new watching her. In an interview on 10/07/25 at 1:10 p.m. with ADON A she stated the CNAs were new CNAs but stated they had been skills checked and in-serviced on infection control, incontinence care and catheter care and stated they all knew the proper steps. She stated she could only assume they were nervous. She stated the Lead CNA does skills checks on all of the CNAs and works closely with them on the floor. She stated the risk of having the urinary bag above the bladder was the back flow of urine which would lead to infection and not changing the surface of the wipes or cleaning from front to back was the introduction of germs. An interview with the Lead CNA on 10/07/25 at 1:20 p.m. she stated catheter care was to be performed anytime the staff provided incontinence care and staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated they were to change the surface of the wipes with each stroke. She stated that by not providing accurate incontinence care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated the staff had also been instructed to maintain the urinary drainage bag below the bladder at all times. She stated she worked directly with the CNAs, and they all knew how to do it correctly. She stated she thinks they just got nervous. An interview with the Corporate Nurse on 10/07/25 at 2:30 p.m. she stated it was the expectation for all staff to provide timely and appropriate incontinent care and catheter care. She stated she could attribute some of it to nerves but stated they would do some re-education to ensure staff were following the correct procedures. She stated the risk of having the urinary bag above the bladder was the back flow of urine which would lead to infection. Record review of the facility's undated policy titled, Incontinence, reflected, .The facility will ensure that the resident who is incontinent receives appropriate treatment services to prevent urinary tract infections. Record review of the facility's undated policy, Catheter Care, reflected, Put on gloves.Wash the area around the catheter and perineal are well with mild soap and warm water, taking care to wash from front to back. DO NOT COMATAMINATE AREA WITH FECES. IF CONTAMINATION OCCURS WSAH YOUR HANDS AND OBTAIN CLEAN EQIPIPMENT TOR CATHETER CARE. Wash the catheter by cleaning gently from the meatus outward. For males, retract foreskin 0.5 to 1 inch to cleanse, being sure to replace it when finished.Cleanse area at catheter insertion well.Cleanse tubing with soapy and water in downward motion.Procedure should be done at least daily and after each bowel movement.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 Residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) observed for infection control. 1.The facility failed to ensure CNA B performed hand hygiene during incontinence care to Resident #1 and failed to perform hand hygiene prior to leaving the resident's room on 10/07/25. 2. The facility failed to ensure CNA B used the required PPE for Resident #2, who was on Enhanced Barrier Precautions due to his urinary catheter, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and failed to perform hand hygiene before leaving the resident's room on 10/07/25. 3. The facility failed to ensure CNA C performed hand hygiene after assisting with Resident #3's mechanical lift transfer and before leaving the resident's room on 10/07/25. 4. The facility failed to ensure CNA D used the required PPE for Resident #4, who was on enhanced barrier precautions due to her urinary catheter and wound, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and failed to perform hand hygiene before leaving the residents room on 10/07/25. 5. The facility failed to ensure CNA C performed hand hygiene during incontinence care to Resident #5 and both CNA C and CNA B failed to perform hand hygiene prior to leaving the resident's room on 10/07/25. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record review of Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 11/27/24. Diagnoses included fracture of left femur, (thigh bone) mild intellectual disability and history of trans ischemic attacks (a brief stroke-like attack resolving within minutes to hours) In an observation on 10/7/25 at 08:45 a.m. CNA B was observed using the hand sanitizer in the hallway and then entered Resident # 1's room and asked the resident if he was ready to get up for therapy and the Resident stated no,. CNA B stated he needed to check to see if he needed changed and the Resident stated OK. CNA B put on gloves pulled out a packet of peri-wipes and a clean brief from the chest of drawers and uncovered the resident revealing he had brown rings noted on the bed pad. CNA B stated this was his first check and change on the resident since he started his 6:00 a.m. shift. CNA B unfasted the resident's brief revealing it was slightly wet. CNA B had the resident roll onto his side and then took a peri-wipe and wiped from the front to the back of the anal area, revealing light brown smears with each wipe. CNA B then pushed the soiled brief down toward the residents' buttocks and rolled the stained sheet under the resident. CNA B changed his gloves but did not perform hand hygiene. He placed a clean sheet, a draw sheet and clean brief under the resident and had him roll to the other side while he pulled the soiled linen out and pulled the clean linen out from under the resident. He had the resident roll back onto his back and fastened the brief without cleaning his pubic area, penial shaft or scrotum. CNA B then unfasted the brief and took a peri-wipe and wiped once down each groin and refastened the brief and straightened the residents covers. CNA B removed his gloves, gathered up the dirty linens and trash and left the room without performing hand hygiene. CNA B walked down the hall, opened the soiled linen room, deposited the soiled linens and trash and then used the hand sanitizer on the wall outside of the door. 2. Record review of Resident #2's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 10/04/25. Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and severe sepsis (body's extreme reaction to an infection) In an observation on 10/07/25 at 09:10 a.m. signage was observed outside of Resident #2's room which indicated he was on Enhanced Barrier Precautions. CNA B entered Resident #2's room, put on gloves, but no gown and told him he was here to get him changed and dressed for therapy. CNA B went to the resident's bathroom to retrieve a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 220 cc of clear yellow urine. CNA B emptied the urinal, changed gloves but did not perform hand hygiene. CNA B unhooked the urinary catheter drainage bag and laid it on the bed and unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped up the penile shaft up and down with several swipes, using the same wipe and without changing the surface of the wipe. CNA B did not clean the catheter tubing from the tip of the penis downward. Resident's penile shaft and groin area were noted to be red and irritated. CNA B rolled the resident to his side and wiped the anal area from front to back and placed a clean brief under him. CNA B then removed his gloves and without performing hand hygiene, searched the resident's chest of drawers for barrier cream. CNA B put on clean gloves, with no hand hygiene and applied barrier cream to his buttocks and then rolled the resident over and the same gloves applied barrier cream to his groin area and penial shaft. CNA B fastened the brief, removed his gloves and put on clean gloves with no hand hygiene and dressed the resident. CNA B removed his gloves, gathered the soiled linen and trash and left the room without performing hand hygiene. CNA B again walked down to the soiled linen closet on the hallway, disposed of the trash and linen and used the hand sanitizer outside of the door. 3. Record review of Resident #3's Face Sheet dated 10/7/25 reflected a [AGE] year-old female with an admission date of 10/03/25. Diagnoses included diabetes and chronic embolism and thrombosis of unspecified popliteal vein (blood clot that had formed in a deep vein in the lower leg located behind the kneecap). In an observation on 10/07/25 at 09:50 a.m. revealed CNA C and Lead CNA preparing to transfer Resident #3 with a mechanical lift. Both staff had on gloves, positioned the lift over the resident and transferred her from her bed to the wheelchair. Lead CNA removed her gloves, performed hand hygiene and left the room with the mechanical lift, while CNA C brushed the resident's hair. After completion of care, CNA C removed her gloves, gathered the trash and soiled linens and left the room without performing hand hygiene and walked down the hallway to the soiled linen closet, deposited the trash and linens and then used the hand sanitizer outside of the doorway. 4. Record review of Resident #4's Face Sheet dated 10/7/25 reflected an [AGE] year-old female with an admission date of 07/19/25. Diagnoses included candidiasis of the skin and nails (fungal infection especially in warm moist areas) dementia and urinary tract infection. In an observation on 10/07/25 at 10:15 a.m. signage was observed outside of Resident #4's room which indicated she was on Enhanced Barrier Precautions. CNA D used the hand sanitizer on hallway and entered Resident #4's room, put on gloves, but no gown and told her she was here to change her. CNA D uncovered the resident revealing she had urinary catheter that was secured to her right thigh. CNA D unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped opened the resident's labia and wiped down the catheter tube using changing the surface of the wipe with each stroke. Resident was noted to be very red in her groin area. CNA D rolled the resident to her side revealing her buttocks to be very red and irritated and she had a dressing on her coccyx area. CNA D stated they had ordered cream for the resident's buttocks but stated the nurse would have to apply it. CNA D wiped from front to back and while wearing the same soiled gloves, placed a clean brief under the resident. CNA D repositioned the resident on her back and fastened the brief. CNA D removed her gloves, gathered the soiled trash and left the room without performing hand hygiene. CNA D walked down to the soiled linen closet on the hallway, disposed of the trash and used the hand sanitizer outside of the door. 5. Record review of Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 04/20/24. Diagnoses included primary lateral sclerosis (a rare progressive neurodegenerative disease that affects the central motor system in adults), neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired) and adult failure to thrive (a decline in older adults that manifest as a downward spiral of health and ability). In an observation on 10/07/25 at 10:38 a.m. revealed CNA B and CNA C entered Resident #5's room to transfer resident from his recliner to the bed for incontinent care and bed bath. Both staff washed their hands, put on gloves and gowns. CNA B retrieved a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 320 cc of clear yellow urine. CNA B emptied the urinal, changed gloves and washed his hands. Both staff hooked the mechanical lift sling to the lift and CNA C unhooked the urinary catheter drainage bag and laid it on the resident's lap. CNA B instructed CNA C to hang the urinary bag on the lower rung of the mechanical sling, which she did, but as they were raising the lift, Resident #5 pointed towards his feet, and CNA C unhooked the urinary drainage bag and once again placed it on the resident's lap. Urine was observed in the tubing draining back toward the residents. The resident was transferred from the recliner onto his bed. Both staff rolled the resident side to side to remove the sling and CNA C unfasted the brief and provided catheter care, wiping downward from the tip of the penis down, changing each wipe. CNA C then wiped down each groin. CNA B then placed the urinary drainage bag onto the bed, and CNA C told him to place it back on the bed rail. CNA B stated no it was fine on the bed. Both staff rolled the resident over on his side revealing he had large soft bowel movement. CNA C wiped from the front to the back, changing wipes with each swipe. CAN C then removed her gloves and put on new gloves without performing hand hygiene and both staff proceeded to provide resident his bed bath. In an interview with CNA D on 10/07/25 at 11:10 a.m. She stated she had received training and had been skills checked on incontinence care and enhanced barrier precautions. She stated she realized she had forgot to put a gown on when she went in to provide incontinence care to Resident # 4 and she should have changed her gloves and done hand hygiene after she finished cleaning her. She stated she was supposed to wash her hands before she left the room. She stated all of this was to prevent the risk of infections and spreading germs to other residents. In an interview on 10/07/25 at 11:15 a.m. with CNA B he stated he was supposed to perform hand hygiene before providing care and after you finished care. When asked about the proper steps for catheter care and incontinence care he stated he was supposed to go from front to back and wipe away from the body down the catheter tube. He stated he had changed his gloves but did not perform hand hygiene. He stated the signage on the door determine what type of precaution to a resident was in and what PPE needed to be worn. He stated he just forgot to put the gown on in Resident #2's room. He stated he had received infection control training on the enhanced barrier precautions and hand hygiene and stated the risk of not following the proper protocol was the spread of germs and infections. He stated he knew the catheter bag was to remain lower than the bladder but did not think it was an issue placing it on the bed. In an interview with CNA C on 10/07/25 at 11:40 a.m. she stated she was supposed to perform hand hygiene before care, after changing gloves and after care. She stated she realized she had forgotten her hand sanitizer when she went into Resident #5's room and should have washed her hands before she left Resident #3 room. She stated she knew she was supposed to keep the urinary drainage bag below the resident bladder but stated Resident #5 liked to hold the bag and she did not want to be rude. She stated she had only been a CNA for about a year, but state the facility had skills checked them and the Lead CNA had watched her several times. She stated knew it was important to perform hand hygiene correctly to prevent the spread of germs from resident to resident. In an interview on 10/07/25 at 1:10 p.m. with ADON A she stated staff were to wash their hands before care, change gloves and wash their hands when they went from dirty to clean, and after care was completed. She stated enhanced barrier precautions were noted on each resident who required extra PPE and expected the staff to always follow it. She stated the risk to residents was developing infection. She stated the three CNAs were all new CNAs but stated they had been skills checked and in-serviced on infection control. She stated the Lead CNA does skills checks on all of the CNAs and works closely with them on the floor. An interview with the Lead CNA on 10/07/25 at 1:20 p.m. she stated all of the staff had been instructed to wash their hands before care, after gloves changes and before leaving the room. She stated they had also been trained on which residents required Enhanced Barrier Precautions. She stated all of the residents who were on Enhanced Barrier Precautions had signage outside of their doors and supplies in their room. She stated she worked directly with all three of the CNAs and they all knew how to do it correctly. An interview with the Corporate Nurse on 10/07/25 at 2:30 p.m. she stated it was the expectation for all staff to adhere to the infection control protocol. She stated they would do some re-education to ensure staff were following the correct procedures. She stated she knew they had all been taught to wash their hands after incontinence and prior to leaving the room. Record review of the facility's undated policy, Enhanced Barrier Precautions (EBP), reflected, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistance organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with Standard Precautions and expand the use of PPE to donning gown and glove use during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hand and clothing. EBP are indicated for resident with.Wounds and/ or indwelling medical devices even if resident is not known to be infected or colonized with a MDRO.Indwelling medical device example.urinary catheters.feeding tubes.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 11 (Resident #10 and Resident #77) residents reviewed for Respiratory Care. The facility failed to ensure Resident #10's nasal cannula (flexible tube used to deliver oxygen to the nose through two prong) was stored in a bag when not in use on 04/27/2025. The facility failed to ensure Resident #77's nebulizer face mask was stored in a bag when not in use on 04/27/2025. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Resident # 10 Review of Resident #10's Face Sheet, dated 04/28/2025, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #10 was diagnosed with COPD (a chronic lung disease that limits airflow to the lungs). Review of Resident #10's Quarterly MDS Assessment, dated 04/09/2025, reflected moderate cognitive impairment with a BIMS score of 09. Section O (special treatments, procedures, and programs) indicated Resident #10 received intermittent oxygen therapy. Review of Resident #10's Comprehensive Care Plan, dated 04/08/2025, reflected the resident was administered oxygen therapy. Interventions included Apply oxygen as needed and Assess lung sounds PRN & document. Review of Resident #10's Physician's Orders, dated 04/03/2025, reflected an order to administer oxygen 2-4 LPM (oxygen flow rate) via nasal cannula as needed for shortness of breath. During an observation and interview on 04/27/25 at 9:25 AM, Resident #10 was sitting in a recliner in her room. Resident #10's oxygen tubing was connected to the oxygen concentrator next to the recliner. The oxygen tubing was on the floor between the recliner and the oxygen concentrator. Resident #10 stated someone would come and put the oxygen tubing in a bag. Resident #10 pulled the tubing from the floor and draped it over the oxygen concentrator. During an observation on 04/27/2025 at 9:45 AM, Resident #10's oxygen tubing was draped over the oxygen concentrator. It was not stored in a bag. During an interview on 04/27/25 at 9:49 AM, CNA C stated Resident #10's oxygen tubing should have been bagged so it did not get dirty. She stated if a resident used oxygen tubing that was dirty, it could cause them to get sick. She stated some residents already had a weakened immune system and it was important to ensure the oxygen tubing was stored in a bag. CNA C stated she would get new tubing and put it in a bag. Resident #77 Review of Resident #77's Face Sheet, dated 04/28/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #77 was diagnosed with COPD and anxiety disorder (uncontrollable feelings of anxiety and fear). Review of Resident #77's Quarterly MDS Assessment, dated 02/06/2025, reflected moderate cognitive impairment with a BIMS score of 12. Section I (active diagnoses) indicated Resident #77 was treated for COPD. Review of Resident #77's Comprehensive Care Plan, dated 04/07/2025, reflected the resident had the potential for altered respiratory status and difficulty breathing related to COPD. One intervention was to administer medication as ordered and monitor for effectiveness and side effects. Review of Resident #77's Physician's Order, dated 06/08/2023, reflected administer Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 dose inhale orally via nebulizer every 6 hours for SOB. During an observation and interview on 04/27/25 at 9:58 AM, Resident #77 was lying in bed watching television. Resident #77's nebulizer mask was on her nightstand and not bagged. Resident #77 stated it was not always stored in a bag. During an interview on 04/27/25 at 10:05 AM, CNA D stated Resident #77's nebulizer mask should have been bagged when she was not using it. CNA D stated dust could get on the mask and the resident had to put it on her face. She stated the resident could get sick if she got germs in her lungs. She stated it was really important for it to stay in a bag. She stated the nebulizer mask and tubing would be discarded and the new mask and tubing bagged. During an interview on 04/28/25 at 9:15 AM, ADON B stated it was important to keep all respiratory items bagged when the resident was not using them to help prevent infection. She stated it also prevented the residents from tripping on the tubing. During an interview on 04/28/25 at 9:22 AM, ADON A stated all respiratory items should be bagged when not in use. She stated she talked to the nurse to ensure this was done. She stated it was important to keep respiratory items as clean as possible to help prevent infection During an interview on 04/28/25 at 12:12 PM, the DON stated the nurses and aides were responsible for ensuring the respiratory items were bagged. She stated if a resident was cognitively aware, they can be told to place the item in the bag after use. She stated it was important to keep those items clean because the resident breathes through them. She stated all staff had been educated on following this infection control measure. During a telephone interview on 05/01/2025 at 2:12 PM, LVN G stated after completing a breathing treatment, it was important to assess the resident, remove the mask, sanitize it, and tie it up in a bag. He stated it was important to keep it sanitary and prevent infection. The facility did not provide a policy on how to store respiratory items when not in use.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 28 (Residents #85 and Resident #125) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #85 and Resident #125's rooms were in a position that was accessible to the residents on 04/27/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #85 Record review of Resident #85's Face Sheet, dated 04/28/2025, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #85's diagnoses included neurocognitive disorder with Lewy bodies (progressive brain disorder affecting cognition, behavior, movement, and sleep) and muscle wasting and atrophy (loss of muscle mass). Record review of Resident #85's Quarterly MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 02/25/2025, reflected intact cognition with a BIMS (screening tool to assess cognition) score of 13. Section GG (functional abilities) indicated Resident #85 required moderate assistance with self-care and mobility. Record review of Resident #85's Comprehensive Care Plan, dated 03/20/2025, reflected a history of falling or other identified risk factors that result in increased risk of falling. One intervention was Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an observation and interview on 04/27/25 at 9:34 AM, Resident #85 was lying in bed awake. Her call light was on the floor near the head of the bed. Resident #85 was unable to participate in an interview due to her cognitive status. During an interview on 04/27/25 at 9:44 AM, CNA C stated Resident #85 was on hospice care and declining. CNA C stated it was important to ensure Resident #85's call light was in reach so she could notify staff if she needed anything. CNA C went to Resident #85's room and placed the call light on the bed near her. Resident #125 Record review of Resident 125's Face Sheet, dated 04/28/2025, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #125 had diagnoses which included congestive heart failure (heart does not pump blood efficiently), COPD (chronic lung disease), and muscle weakness. Record review of Resident #125's Quarterly MDS Assessment, dated 04/22/2025, reflected severe cognitive impairment with a BIMS score of 06. Section I (active diagnoses) reflected muscle weakness and Section O (special treatments, procedures, and programs) indicated Resident #125 received physical therapy services. Record review of Resident #125's Comprehensive Care Plan, dated 04/17/2025, reflected a history of falling or other identified risk factors that result in increased risk of falling. One intervention was Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an observation and interview on 04/27/25 at 10:20 AM, Resident #125 was sitting in her wheelchair next to her bed. Resident #125's bedside table was in front of her. Resident #125's call light was on the bed rail on the opposite side of the bed. Resident #125 stated she could not reach her call light. During an observation and interview on 04/27/25 at 10:22 AM, CNA E stated she transferred Resident #125 to her wheelchair and forgot to move the call light where the resident could reach it. CNA E went to Resident #125's room and handed the call light to the resident. She stated Resident #125 was not able to get up and get the call light on her own. CNA E stated it was important for the resident to have the call light in case she needed assistance or had a change of condition. During an interview on 04/28/2025 at 9:16 AM, ADON B stated residents should have their call lights within reach at all times. She stated call light placement was to be checked during rounds. ADON B stated all staff members were responsible for ensuring residents could reach the call light before leaving their rooms. During an interview on 04/28/2025 at 12:12 PM, the DON stated her expectation was that call lights were always in reach for the residents' safety. The DON stated if residents needed help and tried to get up, they could fall and get hurt. She stated she was in-servicing staff. During an interview on 04/29/2025 at 11:55 AM, LVN F stated it was important for residents to have their call light or they would not have a way to reach staff for assistance. She stated sometimes residents needed a drink, their television remote, or assistance to get up and go to the restroom. She stated staff had to be there to meet whatever needs the resident had. During an interview on 04/29/25 at 2:10 PM, the Administrator stated all staff members were responsible for ensuring residents' call lights were in reach before leaving the room. He stated administrative personnel had assigned residents they rounded on each day to ensure residents' needs were being met and that included ensuring the call light was accessible. He stated it was important for residents to be able to notify staff if they needed assistance with anything. Record review of the facility's policy Call Lights reflected The call light must always be within resident's reach before you leave the room.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident#3) of 3 residents reviewed for ADL's. The facility failed to ensure. 1-Resident #1 had her facial hair shaved. 2- Resident#3 had her fingernails trimmed and cleaned. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (result of disrupted blood flow to the brain due to problems with blood vessels that supply it), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), and hypertension (High blood pressure). She had a BIMS score of 06/15 indicating severe cognitive impairment. She was totally dependent with personal ADLs. Record review of Resident #1's Comprehensive Care Plan last revised 12/19/24 reflected the following Focus. Resident #1 requires assist with ADLs. Goal. The resident#1 is able to perform self-care to optimal level and maintains strength and endurance x90 days. Intervention. Provide level of support to complete dressing . personal hygiene and bathing needs Observation/interview on 03/12/25 at 09:38 AM revealed Resident#1 was lying in bed. Resident#1's chin had long scattered white hair, and there were white hairs on both sides of Resident#1 upper lips corners. Resident#1 stated she would like the hair in her face removed and she used to pull it out but could no longer do for herself. Interview on 03/12/25 at 11:23 AM with CNA A, she looked at Resident#1's face and stated she was in the process of preparing to give Resident#1 a bed bath. CNA A stated she will remove the resident facial hair, after the bed bath. CNA A stated it was the responsibility of the CNAs to make sure residents were groomed, and to remove the facial hair for female resident if the resident agreed. CNA A stated the risk to the resident was loss of dignity. Interview on 03/12/25 at 11:26 AM with LVN D, she stated the CNAs were supposed to remove female residents' facial hair. LVN D stated it was the responsibility of the charge nurse for the Hall to make sure the residents were cleaned and groomed. She stated the risk to the resident was that she could be embarrassed. LVN D further stated, she would be embarrassed if she was left with her face like that. 2-Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement, muscle tone, and posture), seizure disorder (a neurological condition characterized by recurrent uncontrolled jerking, loss of consciousness, blank stares caused ny abnormal electrical activity in the brain), and anxiety. She had a BIMS score of 02/15 indicating severe cognitive impairment. She required substantial/maximal assistance with personal hygiene. Record review of Resident #3's Comprehensive Care Plan last revised 01/01/25 reflected the following Focus. Resident #3 requires assist with ADLs. Goal. The resident#3 is able to perform self-care to optimal level and maintains strength and endurance x90 days. Intervention. Provide level of support to complete dressing . personal hygiene Observation/Interview on 03/12/25 at 10:08 AM revealed Resident#3 was up in her wheelchair in the Hall 100 common area. Resident#3 had long fingernail approximately 0.7 cm on both hands, with clear brown matter underneath. Resident#3 was unable to answer questions. Interview on 03/12/25 at 10:10 AM with CNA B, she looked at Resident#3's fingernail and stated they were long and some of them were dirty underneath. CNA B stated Resident#3's fingernails needed to be cleaned and trimmed. She further stated the risk to the residents were that they could scratch them self and develop infection. Interview on 03/12/25 at 10:48 AM with RN C, she stated both CNAs and charge nurses in the Halls were responsible for residents' nail care. She stated if a resident had diabetes, only nurses were allowed to trim resident's nails. She stated the risk for not performing nailcare was increased risk of infection and skin break down. Interview on 03/12/25 at 2:25 PM with the DON, she stated her expectation was that nail care should be provided every shower day and as needed. She stated that both CNAs and charge nurses were responsible for doing nail care on all residents; except Nurses were responsible for nailcare if resident had diagnosis of diabetes. The DON stated residents who had dirty fingernails could be an infection control issue. Record Review of the facility undated policy titled Nail Care-Fingernails and Toenails reflected, Purpose: 1. To promote cleanliness 2. To prevent injury 3. To prevent infection The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Record Review of the facility undated policy titled Bath, Shaving the Resident reflected, Purpose: 1. Personal Hygiene 2. Dignity.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering of drugs and biologicals, to meet the needs of each resident for 1 of 1 medication carts (nurses cart Hall 100) reviewed for pharmacy services. The Nurses Cart Hall 100 contained a blister pack for Resident #4 that was broken. This failure could place residents at risk of not having the medication available due to possible drug diversion, diminished effectiveness, and not receiving the therapeutic benefits of the medications. Findings Include: Observation and record review on 03/12/25 at 10:14 AM of nurses' cart Hall 100, with RN C revealed: - the blister pack for Resident #4's Tramadol 50 mg Hcl (controlled medication used for pain) had 1 blister seal broken, the pill was still inside the broken blister. Interview on 03/12/25 at 10:23 AM, RN C stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blisters. She stated the risk to the residents would be a potential for drug diversion. She stated the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the DON. Interview on 03/12/25 at 02:25 PM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON further stated the pharmacist do monthly audit of the medication carts for monitoring. Record review of the facility undated policy titled Narcotic count, revealed: The oncoming licensed nurse or certified medication aid will prepare to count narcotic medications with the off-going nurse or certified medication aide .a. any discrepancy will immediately be reported to the charge nurse and/or ADON, who will attempt to reconcile the discrepancy. b. The ADON will notify the DON if any discrepancy cannot be reconciled .

Based on observation, interviews and record reviews the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (Resident #2) reviewed for documentation of wound care dressing changes. The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident # 2 on 02/09/25, 02/13/25, 03/01/25, 03/02/25 and 03/09/25. These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection. Findings included: Record review of Resident #2's quarterly MDS assessment, dated 02/26/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE], and readmitted on [DATE]. She had a BIMS score of 06/15, which indicated her cognition was severely impaired. Resident #2 had diagnoses which included dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), wound infection, cellulitis of right lower limb, and acquired absence of toe. Further review revealed skin and Ulcer/injury treatment, surgical wound care application of nonsurgical dressings. Record review of Resident #2's care plan, with an onset date of 03/06/25, reflected focus. I have an amputation of right 1st toe. Goal. The resident's wound will heal and progress without complications through the review date. Intervention. Check and document on wound daily for s/sx of infection, drainage, any breakdown of skin and impaired circulation (edema or pain). Record review of Resident#2's Doctor orders revealed: 1- Order started date: 01/10/25, end date 02/17/25: R foot-surgical site cleanse with betadine cover with dry dressing one time a day every other day. 2- Order started date: 02/22/25 end date 03/05/2025: R foot-surgical site cleanse with ns, apply silver alginate and cover with dry dressing one time a day. 3- Order started date: 03/05/25: R foot-surgical site cleanse with ns, apply Santyl ointment and cover with dry dressing one time a day. Review of Resident#2's TAR for the months of February 2025, and March 2025 revealed no documentation for wound dressing change on 02/09/25, 02/13/25, 03/01/25, 03/02/25 and 03/09/25. An observation on 03/12/25 at 10:37 AM, revealed Resident #2 was sitting in her wheelchair in her room. LVN E entered the resident's room to change the wound dressing on Resident#2's right foot. LVN E removed the resident's right shoe, and sock. Resident#2's wound dressing was not dated, timed, or initialed. In an interview on 03/12/25 at 11:22 AM, LVN E (The wound care nurse) stated the facility did not have a policy for wound dressing dating, timing, and initialing. LVN E stated for her or any other staff to know when the dressing was last been changed, they had to check the TAR. She further stated if the wound care dressing change was not documented in the TAR the staff will not know the last time it had been done. She stated the risk to the resident could be missed treatment, and development of infection. In an interview on 03/12/25 at 11:26 AM, LVN D stated for the wound dressing care, she would put the date and initial on the dressing. LVN D stated the purpose of the date on the wound dressing was to know when it was changed. In an interview on 03/12/25 at 1:35 PM, ADON E stated when the wound care dressing was changed, personally, she would date the wound dressing. In an interview on 03/12/25 at 2:25 PM, the DON stated the facility did not have a policy for wound care change dressing dating, timing, and initialing. The DON stated there was no regulation indicating to date the wound dressing. The DON stated she trusted the staff documentation on the resident TAR, and to know when the last time the resident's wound dressing had been changed was by checking the TAR documentation. The DON stated the risk to the resident missed treatments, and wound deterioration. Record Review of the facility undated policy titled Wound Care reflected, Purpose: 1. Treat wounds with the appropriate products .Documentations: 1. Assessment of the wound 2. Treatment 4. Effectiveness of the treatment.

Based on observation, interview and record review the facility failed to treat residents with respect and dignity for 1 of three (Resident #1) residents reviewed for dignity in that: Facility staff stood over Resident #1 while assisting the resident with her meal in the dining area. This failure could affect residents who require assistance with activities of daily living and placed them at risk for psychosocial harm due to a diminished quality of life. The findings were: Review of Resident #1's electronic face Sheet printed 3/28/24 reflected a [AGE] year-old-female initially admitted on [DATE] with diagnoses including but not limited to the following: dysphagia (difficulty swallowing), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident #1's Quarterly MDS, dated [DATE] reflected Resident #1 was rarely/never understood. Review of Section GG of Resident #1's MDs revealed partial/ moderate assistance eating. Review of Resident #1's Care Plan revised 11/17/2023 reflected the following problems: The resident has potential for altered nutritional status regarding Dementia. Regular diet 5/8/23- Change diet to Mechanical soft consistency ,11/16/23- Nectar consistency liquid, Date Initiated: 03/26/2021 Revision on: 11/17/2023. Review of the facility provided list on 03/28/2024 of residents who required full assistance with feeding revealed the list included Resident #1. Observation on 03/28/24 at 12:12 PM in the dining hall revealed Charge Nurse A was observed standing over Resident #1 and assisting her with feeding her the meal by placing food in her mouth with a utensil. There was a vacant chair observed next to the resident. In an interview on 03/28/24 at 12:20 PM Charge Nurse A revealed she was assisting Resident #1 with feeding temporarily until the other caregiver returned. Charge Nurse A stated staff typically sit down and assist the resident throughout their entire meal however she was only assisting until the other staff member returned. The Charge Nurse stated standing over the resident and feeding her could be a dignity issue however she was only helping out until the other caregiver returned. In an interview with the Director of Nursing on 03/28/24 at 3:36PM revealed if staff were assisting with feeding during meals then they should be sitting down and helping the resident until the meal is completed. The Director of Nursing stated Resident #1 did require full assistance with eating. The Director of Nursing stated if a staff is standing over a resident while assisting during meals then the resident rights could be violated. Record review of the policy Operational/resident care policies undated revealed The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. The facility will protect and promote the rights of each resident.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #74) of 8 residents reviewed for comprehensive care plans. The facility failed to create and implement a care plan that reflected the Resident's preference to speak Spanish. This failure could put the Resident at risk of not being able to communicate effectively with staff, which could result in isolation, reduced psychosocial well-being, and of not getting her needs met in a timely manner. Findings included: Review of Resident #74's face sheet undated reflected a [AGE] year-old female admitted to the facility on [DATE] and diagnosis of unspecified dementia (loss of cognitive functioning), unspecified severity, , insomnia (sleep disorder), unspecified anxiety disorder (a condition in which a person has excessive worry and feelings of fear or unease), hypertension (high blood pressure), muscle weakness (generalized), muscle wasting and atrophy, other abnormalities of gait (manner of walking) and mobility, history of falling. Record Review of Resident #74's admission document titled dated [DATE] revealed Resident #74 was Spanish speaking only. Record review of Resident #74's Admissions MDS assessment dated [DATE] and Quarterly MDS dated [DATE] and [DATE] revealed Resident #74 resident preferred speaking Spanish and needed an interpreter to communicate with doctors and staff. Record review of Resident #74's Quarterly MDS dated [DATE], [DATE], and [DATE] revealed Resident #74 preferred language was Spanish and she did not want or need an interpreter. Record Review of Resident #74's care plan dated [DATE] revealed there was no care plan for Resident's preferred language of Spanish. Record Review of Resident #74's progress note date [DATE] by Previous Activities Director: Every time I go in the room now she closes her eyes and pretends to be asleep. I'm not sure it is a good idea to continue one to one visits with her. The language barrier is an issue and she is not interested in having me visit. Record Review of Resident #74 progress note dated [DATE] by Previous Activities Director: there aren't adequate materials in the file for Spanish Resources. Everything in the file folder is in Spanish. I pointed this out to my supervisor and she told me to do my best and figure it out. Observation of Resident #74 on [DATE] at 11:08 AM revealed the resident was laying in bed watching television in Spanish with call light and water cup within reach. Resident #74's room had the lights on low and pictures were on nightstand next to the resident's bed with additional pictures on top of furniture underneath the television. Surveyor attempted an interview and resident raised her hand and indicated she only spoke Spanish. Interview on [DATE] at 11:54 AM with Resident #74 with translation by CNA D revealed resident laying in bed with television on a Spanish channel, with a blanket, call light within reach, and water cup on bed side tray. Resident #74 stated that she did not have concerns with abuse or neglect and staff were kind to her. Resident #74 stated that she did not know what a communication board was and did not remember anyone asking her about a communication board. Interview [DATE] at 11:57 AM with CNA D revealed a communication board that Resident #74 could point to show what she needed such as water or if she were in pain, would be helpful for Resident #74. CNA D stated that, if needed, staff could also get the Spanish-speaking housekeeping staff to translate for Resident #74. Interview on [DATE] at 2:00 PM with the Speech Therapist revealed she was aware that Resident #74 was Spanish-speaking only and there were no interventions to use for resident. The Speech Therapist stated she did not speak Spanish. Speech Therapist stated she did not do care plans. The Speech Therapist stated that if a resident had a communication deficient then it should be care planned. The Speech Therapist stated that when residents needed interventions, she was responsible for training staff on what resident needs. The Speech therapist stated she did not do care plans and would report to charge nurse if there was an issue or a resident needed an issue care planned. Interview with the MDS Coordinator on [DATE] at 2:16 PM revealed she was aware that Resident #74 spoke Spanish but thought she was able to make her needs known by saying yes or no and indicating with body language. The MDS Coordinator stated Resident #74's language limitation was not care planned. The MDS Coordinator stated he spoke with her everyday by asking her how she was and she always said she was good, and anytime he asked if he can check her fridge for expired food she tells him yes. The MDS Coordinator stated that communication deficits should be care planned. Interview on [DATE] at 2:20 PM with LVN B revealed she that had been at facility about 5 years PRN (as needed). LVN B stated she spoke Spanish and communicated in Spanish with Resident #74 because that was her preferred language. LVN stated that Resident #74 communicated in English a little with examples of: yes, no, a little bit. LVN B stated that residents with communication deficits should be care planned. LVN B stated that staff could also get housekeeping to assist if they needed translation assistance. LVN B stated that something like a communication board would be helpful for Resident #74. Interview on [DATE] at 2:30 PM with CNA E revealed she was responsible for scheduling staff. CNA E stated that she did not purposely schedule Spanish-speaking CNA's and nurses for Resident #74 hall and that they just happen to have Spanish speakers on every shift. CNA E provided a highlighted list of Spanish speaking staff. CNA E stated that she communicated with Resident #74 and resident would say yes and no and sometimes more than that. CNA E stated she probably could schedule Spanish speakers for that hall, and that housekeepers are usually available if staff needed someone to translate in Spanish for resident or staff. CNA E agreed that a communication board would probably be helpful for Resident #74. CNA E stated that resident arrived to facility able to communicate fairly well in English and perhaps she had a decline. Interview with the Personal Care Assistant (PCA) on [DATE] at 8:40 AM revealed Resident #74 mainly spoke Spanish and a little bit of English like Yes, No, or Wet to indicate she needed to be changed and that he can usually communicate with her. The PCA stated that if he needed a translator, he could get a housekeeper to translate. The PCA stated he had to get a housekeeper to translate, before, when she was refusing to shower. The PCA stated that Resident #74 had never spoken more English than she had today. The PCA stated that a communication board would be helpful to ensure Resident #74's needs were addressed and did not know why they did not have one for resident. Interview on [DATE] at 11:40 AM with the Current Activities Director (CAD) revealed that she had only worked at facility for 3 weeks and she was not aware they had any Spanish speaking residents. The CAD could not recall Resident #74. The CAD stated that she was aware they have Spanish resources and was able to produce a printed booklet in Spanish only. The CAD stated she couldn't read them because they were in Spanish and she did not speak Spanish so she did not know what kind of resources they were. The CAD also produced a communication board but when asked what the paper was, the CAD replied she did not know and said that the words on the document were in Spanish and the CAD could not read it. The CAD stated if resident preferred Spanish or only spoke Spanish it would be difficult to communicate with resident because the CAD doesn't speak Spanish. Interview on [DATE] at 11:53 AM with the DON revealed she did not think they had any residents that couldn't speak English. DON stated she did not speak Spanish. The DON stated that resident #74 does speak some English, and while she had not had full blown conversations with her, she could communicate her needs. The DON stated that they care planned for residents with communication deficits and coordinated with Speech to develop a communication board for things like pain or other issues. Interview with the Social Worker on [DATE] at 12:13 PM revealed she worked at facility for 3 months and wasn't sure who their Spanish-speaking residents were. The Social worker did not recall speaking with Resident #74. The Social worker stated that if a resident did not speak English it would be challenging to communicate and ensure basic needs. Interview with the Administrator on [DATE] at 12:15 PM revealed he was aware that Resident #74 spoke Spanish and a little English. The Administrator stated that he did not know if Spanish-speaking staff were scheduled purposefully for Resident #74's hall. The Administrator stated that residents with communication deficits should be care planned. The Administrator stated a communication board would be a good idea and would work on getting that for Resident #74. Record review of facility's Comprehensive Care Plan Policy, undated, revealed (i) the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #55) of two residents reviewed for catheter care. 1. The Facility failed to ensure Resident #55's foley catheter was secured prior to transferring Resident #55 from the bed to his wheelchair. 2. The facility failed to ensure CNA B and CNA C maintained the foley catheter drainage bag below Resident #55's bladder during a mechanical lift transfer. This failure placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included: Record review of Resident #55's face sheet dated 02/20/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Primary diagnoses included diabetes, and obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow). Record review of Resident #55's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 15 which indicted he was cognitively intact, required extensive to total assistance with toileting and personal hygiene and was always incontinent of bowel and had a foley catheter. Record review of the Resident #55's care plan initiated on 07/10/23 reflected, The resident has an indwelling catheter related to obstructive uropathy. Interventions included .Position catheter bag and tubing below the level of the bladder .Goal .The resident will be/remain free from catheter-related trauma . Review of Resident #55's Order Summary report dated 02/20/24, reflected, Catheter Care-Catheter drainage bag to gravity. Secure catheter. Check every shift .Change catheter secure device every Wednesday With a start day of 07/07/23. Observation on 02/20/24 at 9:30 a.m. revealed CNA B and RN B entered Resident #55's room to get the resident up for the day. CNA B unhooked the catheter bag from the bed rail and passed it to CNA C, who then then hooked it to the top bar of the mechanical lift, above resident's bladder. The catheter tubing was not strapped to the resident's leg. The staff raised the resident from the bed with the Foley catheter bag hanging above the resident's head. Urine was observed flowing back toward the resident's bladder. The staff then positioned him over his wheelchair and lowered him into his chair and unhooked the catheter bag from the mechanical lift and onto the back of his wheelchair. In an interview with CNA B on 02/20/24 at 09:45 a.m., she stated she had worked at the facility for 3 years. She stated she was trained to make sure the catheter bag was always in a privacy bag, make sure the tubing was not kinked and make sure they emptied the drainage bag each shift. She stated the catheter tubing was supposed to be secured to the resident's leg and it was the nurse who secured it. She stated she was not sure why Resident #55's was not secured and would let the nurse know. When asked about keeping it below the bladder, the CNA was not sure where the catheter bag should have been positioned during the transfer. She stated having it above the bladder could possibility cause blockage and then she stated the urine could run backwards, which could cause an infection. In an interview with CNA C on 02/20/24 at 09:50 a.m. she stated Resident #55's catheter tubing was supposed to be taped to his leg, and stated she was not sure why it was not secured. She stated it was the nurse who took care of that. When asked about the positioning of the foley catheter bag, she stated they should have placed it in his lap, but then stated it would still be above his bladder and stated they should have held the drainage bag below the resident while they transferred him. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with Staff Development on 02/20/24 at 02:15 a.m., she stated the facility did skills checks on all the staff annually or as needed. She stated the staff were taught to make sure the catheter was secured unless the resident had requested it not to be, and then it should be care planned about their request. She stated the nurse was responsible for ensuring the catheter was secured, but the CNAs should let them know if it had come unsecured . She stated they were taught to keep the bag below the bladder to prevent urine flowing back into the bladder. She stated failing to do this could cause increased risk of urinary tract infections and failing to secure the catheter could lead to the catheter being pulled on or accidently dislodgement. In an interview with Resident #55 on 02/20/24 at 02:40 p.m., he stated he did not mind the catheter being taped to his leg. He stated he had oily skin which caused the tape to come off after about a day or two. He stated he just wanted to make sure it did not get pulled during care, because it was very uncomfortable when that happened. In an interview with LVN A on 02/20/24 at 02:45 a.m., she stated the nurse was responsible for securing the catheter, but stated she relied on the staff to let her know if it had become unsecured. She stated if a resident did not wish to have their catheter secured, it had to be care planned. She stated she would make sure Resident #55's catheter secured. In an interview with the DON on 02/20/24 at 03:00 p.m., she stated any resident with a foley catheter should have it secured, unless the resident requested otherwise, and then it should be care planned, to prevent it from pulling and causing pain or dislodgment. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of a urinary tract infection and cross contamination. She stated she would have the Staff development to provide training on positioning of the drainage bag during transfers and the securing the foley catheter tubing. Record review of CNA B's proficiency check off for catheter care revealed she was proficient in care as of 10/11/23. Record review of CNA C's proficiency check off for catheter care revealed she was proficient in care as of 10/06/23. Review of the facility's undated policy titled, Catheter Care , reflected, Purpose: to prevent infection .To reduce irritation .Properly secure catheter .Procedure should be done at least daily .

Based on observation, interview, and record review, the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents observed during a transfer. CNA A failed to use a gait belt when transferring Resident #1 from wheelchair to toilet back to wheelchair. This failure could place residents at risk for discomfort, pain and or injury. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 08/07/23, reflected an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's diagnoses included Alzheimer's, high blood pressure, and dementia. Her BIMs score was 03 revealing the resident was not cognitively intact. Her functional status reflected substantial assistance for toileting hygiene, bed mobility, and transfers. Record review of Resident #1's comprehensive plan of care dated 06/10/22 reflected, Focus: Resident#1 requires assist with ADLs .provide level of support to complete dressing, toilet use, personal hygiene . Observation on 10/04/2023 at 11:05 AM, CNA A was observed as she assisted Resident#1 to the toilet. CNA A rolled Resident #1 in wheelchair into restroom next to the toilet. CNA A locked the wheelchair on both sides. CNA A lightly grabbed jean waist, Resident #1 used rail next to toilet to help pull herself up, CNA A used both her hands to guide Resident #1 to standing. No gait belt was used. CNA A helped to turn and sit Resident #1 on the toilet. After cleaning Resident #1, CNA A helped Resident #1 stand up, Resident #1 pulled on side rail while CNA A placed hand on Resident #1's buttock to help her stand. No gait belt used. CNA A stated, Oops I am sorry and stated she was supposed to use the gait belt anytime she transferred a resident. CNA A stated she has been trained by therapy regarding using gait belts during transfer. CNA A stated that she was not thinking and when she saw Resident #1 soaking wet, she instantly thought she needed to change her. Interview on 10/04/23 at 11:51 AM, the DON stated that nursing staff are to use a gait belt for any resident that require more than limited assistance. The DON stated that using gait belts helped prevent injury and promotes safety. A record review of In-Service Training Report - Topic: Gait belt and hoyer pads, dated 7/3/23, revealed, All aides must have a gait belt on them at all times .CNA A . A record review of the facility's policy Transfer of Patient, no date, reflected . to safely move resident from one place to another . staff will use gait belt to assist in getting resident to stand and guiding resident to pivot .

Based on observation, interview, and record review the facility failed to ensure a resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infection to the extent possible for one (Resident#1) of five residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner. This failure could place residents at risk of a diminished quality of life by not receiving care and services to meet their toileting needs. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 08/07/23, reflected an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's diagnoses included Alzheimer's, high blood pressure, and dementia. Her BIMs score was 03 revealing that resident was not cognitively intact. Her functional status reflected extensive assistance for personal hygiene. She was frequently incontinent of bowel and bladder and requires extensive assistance for toilet use. Record review of Resident #1's comprehensive plan of care dated 06/10/22 reflected, Focus: Resident#1 requires assist with ADLs .has been identified at risk for pressure ulcer development or skin breakdown .check for incontinence frequently and PRN. Provide incontinent care after each episode . Observation on 10/04/2023 at 10:47 AM revealed Resident #1 in wheelchair. Resident #1's jeans were wet from her hips, down her left side to about the middle of her left thigh. Liquid appeared to fall down Resident #1's leg to the puddle. There was a puddle under her leg and foot. The puddle was approximately 2ft by 2ft. Surveyor attempted to interview Resident # 1, but she was unable to answer questions. Observation on 10/04/2023 at 11:05 AM, CNA A assisted Resident#1 to the toilet. CNA A stood the resident up, there was a puddle of liquid where Resident #1 was sitting, removed Resident #1's wet jeans and put into a trash bag. The resident was wearing an incontinent brief which was swollen large with yellow liquid. When asked if the resident had been changed, CNA A stated that hospice bathed her around 06:30 am this morning. CNA A stated that they are to check on residents and change if needed every two hours. The surveyor observed the resident's skin, and no breakdown or redness was noted . Interview on 10/04/23 at 11:51 AM, the DON stated nursing staff are to check residents every 2 hours and change them if they are wet. The DON stated the risk of incontinent care not being provided on time would be skin break down and infection. A record review of the facility's policy Operational/Resident Care Policies, undated, reflected . Incontinence .receives appropriate treatment and services to prevent urinary tract infections .

Based on interview and record review the facility failed to ensure obtain laboratory services were provided as ordered for one (Resident #1) of five residents reviewed for laboratory services. The facility did not obtain a complete blood count (CBC) and comprehensive metabolic panel (CMP) blood draw stat as ordered by the physician on 10/14/22. This failure could place residents at risk for delays in the provision of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 09/09/22, reflected he was a [AGE] year-old male with an admitted [DATE]. Resident #1 was severely cognitively impaired, required extensive two-person assistance with ADLs except for eating he required one-person limited assistance. Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the laboratory requisition dated 10/14/22 indicated Resident # 1 was to have CBC and CMP test. Review of the 24-hour /change of condition report dated 10/14/22 revealed Resident #1 was listed for cough, congestion and drowsy, new medication orders listed, chest x-ray and stat CBC and CMP blood draws. Review of Resident #1's nursing progress note dated 10/14/22 written by (staff ID) revealed new order for Mucinex (medication used to thin [MEDICATION(S)]) and [MEDICATION(S)] (used to treat infections). Stat order for chest x-ray, CBC, and CMP. Interview on 10/19/22 at 9:45 AM with RN A revealed Resident #1 was experiencing cough and congestion on 10/14/22 therefore she contacted the resident's doctor and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN A stated she imputed the stat CBC and CMP blood draw orders into the laboratory electronically and called the laboratory to verify the stat orders. RN A stated she gave report to the oncoming nurse, LVN B at 6:00 PM and documented the stat lab orders on the 24-hour report/change of condition report. RN A stated that Resident #1's chest x-ray revealed pneumonia and was transferred to the hospital on 10/15/22. Interview on 10/19/22 at 11:08 AM with the DON stated that stat blood draw orders are usually done within four hours. Follow up interview on 10/19/22 at 11:22 AM with RN A regarding the results for the stat CBC and CMP for Resident #1. RN A stated she called and imputed the stat CMC and CMP blood draw order for Resident #1 on 10/14/22 around 1:30 PM. RN A stated she got off work on 10/14/22 at 6:00 PM. RN A stated the laboratory has four hours to draw stat labs. RN A stated on 10/15/22 I looked in the computer for Resident #1's CBC and CMP lab results first thing during my shift around 6:00 AM, the results were listed as in transit. The laboratory technician never arrived on 10/15/22 prior to the end of my shift at 6:00 PM. RN A stated that she spoke with Resident #1's doctor on 10/15/22 and the doctor never asked about the CBC and CMP results. RN A stated there have been no prior issues with stat labs orders. RN A stated that Resident #1 was sent out to hospital on 10/15/22 around 3:30 PM. Interview on 10/19/22 at 1:04 PM the ADON stated she would have expected for RN A to give the pending lab report to LVN B and to place the stat lab orders on the 24-hour report. The ADON stated there have been no prior issues with stat lab orders. The ADON stated the risk of not obtaining labs timely could result in a delay of treatment. Interview on 10/19/22 at 2:00 PM the ADM revealed the expectation for a stat lab order to be completed was in four hours. The ADM stated that depending on the time the lab order was imputed would determine who would be responsible for following up it, but in the case of Resident #1's stat CBC and CMP it would have been LVN B's responsibility to follow on the stat labs. The ADM stated we have had issues with obtaining stat labs timely. The ADM stated that a delay in lab results could result in delay in treatment. Interview on 10/19/22 at 2:10 PM, the DON revealed they have had no issues with obtaining stat labs. DON stated the risk of not obtaining labs as ordered could delay treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 10/19/22 at 2:54 PM via telephone with LVN B revealed she remembered RN A giving report about Resident #1's stat chest x-ray order pending on 10/14/22 but she did not recall anything about a CBC or CMP stat blood draw order. LVN B stated she did not review the 24-report until she was writing out a new one towards the end of her shift on 10/15/22 around 2:00-3:00 AM. LVN B stated when RN A arrived on 10/15/22 at 6:00 AM she asked about the stat CBC and CMP blood draw results and she told RN A that no one from the laboratory came, LVN B stated she was not focused on the labs results just the chest x-ray results. LVN B stated the risk of not obtaining labs as ordered could result in a resident not receiving timely treatments. Interview on 10/19/22 at 3:00 PM with the ADM and DON regarding a policy on lab and diagnostic test revealed the facility did not have a policy to provide.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1 and Resident #2) of four residents observed for infection control in that: 1. CNA A and CNA B failed to perform hand hygiene after entering Resident #1's room, during incontinence care and before leaving Resident #1's room. 2. CNA C and CNA D failed to perform hand hygiene during incontinence care for Resident #2 and CNA D failed to remove her gloves and perform hand hygiene before leaving and re-entering Resident #2's room. Theses failure could place residents at risk for infection and cross contamination. Findings included: 1. Review of Resident #1's Face Sheet dated 10/12/22 reflected an [AGE] year-old female with an admitted [DATE]. Resident #1 primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's comprehensive care plan with an initiation date of 08/26/20, reflected Resident has bowel & bladder incontinence .Interventions .Keep skin clean, dry and free from odors .Perineal care after each incontinent episode In an observation 10/11/22 at 2:20 p.m. revealed CNA A pushing Resident #1's in her wheelchair into her room and CNA B retrieving the Hoyer lift to transfer the resident to bed and provide incontinence care. Both staff put on clean gloves without performing hand hygiene and connected the mechanical lift sling onto the mechanic lift and transferred the resident from her wheelchair to her bed. Both staff rolled the resident from side to side and removed the lift sling. CNA A unfastened the resident's brief, revealing the resident had urinated. CNA A provided peri-care, wiping from front to back and then rolled the resident on her left side and cleaned her buttocks from front to back. CNA A then placed a clean brief under the resident without changing her gloves or performing hand hygiene and had the resident roll back onto her right side. CNA B removed the soiled brief and pulled the clean brief under the resident and then assisted the resident back onto her back and both staff fastened the clean brief. Both staff then pulled the resident up in the bed, adjusted the bed linens and removed their gloves. CNA A gathered up the trash and pushed the mechanical lift out into the hallway and placed it into a closet. CNA A then went to the dirty linen closet, deposited the trash and she and CNA B both used the hand sanitizer hanging outside of the soiled linen closet. In an interview with CNA A and CNA B on 10/11/22 at 2:30 p.m. both stated they should have changed their gloves when going from dirty to clean and were supposed to wash their hands before and after care and before they left the room. Both stated they knew they had messed up. When asked if they had been skills checked for incontinence care, CNA A stated it had been several months ago and CNA B stated she had just recently gotten her NA certification. CNA A stated they knew they had to do hand hygiene to prevent the spread of infections. Review of CNA A's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 06/10/22 and was competent to provide care. Review of CNA B's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 04/28/22 and was competent to provide care. 2. Review of Resident #2's Face sheet dated 10/12/22 reflected an [AGE] year-old female with an admitted [DATE]. Residents #2's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's comprehensive care plan with an initiation date of 05/08/19, reflected Resident has bowel and bladder incontinence .Interventions .Keep skin clean, dry and free from odors .Perineal care after each incontinent episode An observation on 10/12/22 at 9:35 a.m. revealed CNAs C and D entered Resident #2's room to provide incontinence and care and get her up for the day. Both staff washed their hands and put on gloves. CNA C unfasted the resident's brief and pushed it back toward the resident's buttocks and cleaned from front to back. Both staff rolled the resident onto her side, revealing she had a small loose bowel movement. CNA C wiped from front to back changing the surface of the wipe with each wipe. CNA C removed her gloves, and re-gloved without performing hand hygiene and placed a clean brief under the resident and rolled her onto her other side. CNA D then applied barrier cream to the resident's buttocks and both staff rolled the resident on her back and fastened her brief. Both staff removed their gloves and re-gloved without performing hand hygiene. Both staff then placed the mechanical lift sling under the resident and finished dressing the resident for the day. CNA C then gathered up the trash, removed her gloves and without performing hand hygiene, left the room to retrieve the mechanical lift. CNA C returned and without putting on gloves or performing hand hygiene, she and CNA D attached the sling to the mechanical lift and transferred the resident from the bed to her wheelchair. CNA D, while still wearing gloves, left the room with the mechanical lift and placed it into the hallway. CNA D returned to the room, still wearing gloves, and she and CNA C adjusted the resident in her chair. CNA C then re-gloved without performing hand hygiene and went to the bathroom to retrieve the resident's dentures. CNA C rinsed the dentures and placed adhesive to the dentures and handed them to the resident, who then placed them in her mouth. Both staff then made the resident's bed, removed their gloves, and washed their hands before leaving the room. In an interview with CNA C and CNA D on 10/12/22 at 10:08 a.m. both stated they were supposed to wash their hands before and after care. CNA C then stated she should have washed her hands after cleaning the resident. She stated she was supposed to perform hand hygiene when she went from dirty to clean. When asked if they were supposed to wear gloves out of the room CNA D stated she was not supposed to wear gloves out of the room and realized she had not removed her gloves when she took the mechanical lift out of the resident's room. When asked if they had training on incontinence care they both stated yes. Both staff stated they were aware failing to perform hand hygiene placed residents at risk of infections. Review of CNA C's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 06/13/22 and was competent to provide care. Review of CNA D's skills checks reflected she had been skills checked on incontinence care, which included hand hygiene, on 03/10/22 and was competent to provide care. In an interview with the DON on 10/12/22 at 10:10 a.m. she stated staff were to perform hand hygiene when they entered a resident's room, after contact with any bodily fluid, and they were to change their gloves and perform hand hygiene during incontinent care when they went from dirty to clean. She stated staff were never to wear dirty gloves when leaving a resident's room. She stated by not following standard precautions with hand hygiene it placed residents at risk of infections and cross contamination. She stated the facility had a corporate educator who was responsible for skills checking all the CNAs. She stated she would be calling her to come to the facility and do some re-education. In an interview on 10/12/22 at 1:12 p.m. with the Corporate Educator she stated she worked with the CNAs who were getting ready to take their certification test. She stated she had worked with CNA C and CNA D and they had absolutely been taught to remove their gloves and perform hand hygiene when going from dirty to clean. She stated she could not recall if she had worked with CNA A and CNA B. She stated she did not do routine skills checks unless requested by the facility. She stated she had already been called by the DON to come to the facility next week and work with the CNAs and provide re-education on proper hand hygiene. Review of the facility's guidelines titled, Your 5 moments for hand hygiene, obtained from the World Health Organization, dated October 2006, reflected, 1. Before patient contact .Clean your hands before touching a patient when approaching him or her .2. Before an aseptic task .Clean your hands immediately before any aseptic task to protect the patient against harmful germs, including the patients' own germs, entering his or her body .3. After body fluid exposure risk .Clean your hands immediately after an exposure risk to body fluids (and glove removal .4. After patient contact .Clean your hands after touching a patient and his or her immediate surroundings when leaving .5. After Contact with Patient surroundings .Clean your hands after touching any object or furniture in the patient's immediate surroundings, when leaving-even without touching the patient Review of the facility's undated policy titled, Perineal Care, reflected, .Knock at door, enter room and identify resident .Wash hands and put on gloves .Separate the female labia with one hand and cleanse the area with downward strokes using a different part of the cloth with each stroke .After front is clean, then dry resident .With a clean washcloth, clean rectum by wiping from front to back .Place the soiled items in a plastic bag or pillowcase for removal from the room .Remove gloves and wash hands. Apply clean gloves and use skin protectant as needed .Remove gloves and wash hands

Based on observation, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #101) of nine residents reviewed for quality of care. The facility failed to immediately consult with Resident #101's physician, who was the Medical Director of the facility, about a chest x-ray result indicating pleural effusion and atelectasis and continued [MEDICAL CONDITION] (swelling caused by an excess of fluid in body tissues) for 31 hours. These failures placed residents at risk for delays in treatments and care which could result in clinical complications and exacerbation of conditions. Findings included: 1. Resident #101's admission record dated 10/31/18 reflected she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's MDS assessment dated [DATE] reflected she was cognitively intact and required occasional assistance of one or two persons for bed mobility, transfers and personal hygiene. Review of the care plan updated 10-22-18 reflected, [DIAGNOSES REDACTED]. Resident #101's nurses note dated 10/23/18 at 2:13 PM reflected, the resident complained of experiencing shortness of breath and she had [MEDICAL CONDITION] present to her upper extremities and her right lower extremity. She had diminished lung sounds present to the left upper lobe. The physician was notified, and a new order was received for [MEDICATION NAME] (diuretic fluid pill) used to treat [MEDICAL CONDITION] due to [MEDICAL CONDITION]) to be increased to 40 mg daily. There was no documentation of monitoring of the resident's lung sounds, [MEDICAL CONDITION], or weights. Resident # 101's nurses' note dated 10-24-18 at 12:35 PM reflected, the resident was noted to have some confusion which was outside of her normal. There was no documentation of further evaluation or notification of the physician. Interview with Resident #101 on 10-29-18 7:45 PM revealed she had been waiting for a facility staff member to let her know whether she would have an x-ray completed. She had been complaining of shortness of breath and increased [MEDICAL CONDITION]. Resident #101's nurses note dated 10-29-18 at 8:48 PM reflected, a new order for [MEDICATION NAME] ( diuretic) 1 mg and a stat chest x-ray. No further documentation was noted as to the cause for the new order. There was no documentation indicating the resident was assessed or being monitored. Resident #101's's nurses note dated 10-30-18 at 6:21 AM reflected, x-ray results indicated a combination of pleural fluid ( an abnormal, excessive collection or buildup of fluid between the layers of tissue that line the lungs and chest cavity. Heart failure is the most common cause) and atelectasis ( collapse or closure of a lung resulting in reduced or absent gas exchange). There was no documentation of notifying the physician. Resident #101's nurses note dated 10-30-18 at 1:15 PM reflected, no response from physician on x-ray results at this time. There was no documentation the facility was continuing to attempt to reach the physician. Resident #101 's nurses note dated 10-31-18 at 1:13 PM reflected, a new order to schedule an outpatient thoracentesis (procedure in which a needle is inserted into the pleural space between the lungs and the chest wall to remove excess fluid, known as a pleural effusion). Review of the 24 hour report for 10-23-18 to 10-31-18 reflected, 10-23-18 Resident #101 had an increase in [MEDICATION NAME] to 40mg by mouth daily for [DIAGNOSES REDACTED]. There were no further entries in the 24-hour report for Resident # 101. Interview with LVN C on 10-31-18 at 1:05 PM revealed that she received the chest x-ray result on 10-30-18 at 6:00 AM and attempted to call the physician with the results but had received no answer. She stated he normally answered the phone right away or called right back if he missed a call but thought maybe he was busy at the hospital and went on with her duties. She stated that she knew that she should have advised the ADON or DON that she could not reach the physician, but she did not do that for this resident. When asked what symptoms of worsening heart failure are, she stated they could vary from shortness of breath, [MEDICAL CONDITION], decreased oxygen saturation, fluid overload and death. She said monitoring that should have occurred for Resident # 101 was for increased [MEDICAL CONDITION], shortness of breath, altered mental status and chest pain. When asked if she had monitored those things for Resident #101, she stated she had not done so. Interview with LVN C on 10-31-18 at 1:15 PM revealed she did not document any assessment or monitoring of resident # 101, but she had documented that there had been no response from the physician in regard to the x-ray results. She did not continue to attempt to contact the physician. Interview with the DON on 10-31-18 at 12:35 PM revealed, the facility process for reporting changes in condition included documenting in the 24-hour report, shift to shift report and nurses notes for the nurses. She stated they did not have a formal system in place to document and track reporting of changes in condition. She stated that it was her expectation that the nurses contact the physician with changes in condition and if they were not able to reach the physician, they should advise her or the ADON, so they can assist or intervene. Interview with the ADON on 10-31-18 at 12:57 PM revealed, the nurses' responsibility is to assess, monitor and document any changes in condition such as [MEDICAL CONDITION], chest pain, shortness of breath, fever, acute pain. They should report the changes to the physician and the responsible party. She stated that the 2pm to 10pm shift should have continued to try to notify the physician and the responsible party, but they did not do it, nor did they let her, or the DON know that they were having difficulty reaching the physician. Interview with the Administrator on 11-01-18 at 11:30 AM revealed, it was his expectation that the medical director answers the phone calls placed to him, and if he happened to miss the call, that he returns the call right away. He stated that the nurses should communicate changes in condition to the DON, the ADON, the physician, and to the responsible party. The administrative nurses should be following up with the nurses and the residents to ensure the interventions are effective. Further interview with the DON on 11-01-18 at 11:45 am revealed, that she trusts the medical director's judgement, and that he should respond in an appropriate amount of time depending on the severity if the situation. When asked what an appropriate amount of time was for Resident #101 's situation, she did not give a time frame. Review of the facility's undated policy titled Section D Daily List reflected, Purpose: 1. Ensure continuity of care .Policy. 1. Any acute illness of episode or change in condition, . they are left in the acute rack for the duration of treatment .3. New medication order- .If new medication will or may cause a status change in resident; (EXAMPLE) .Cardiac .medication, resident needs to stay in acute rack for 72 hours (at least). Review of the facility's undated policy titled Change of Condition - Notification reflected, Purpose: to notify that the resident has had a significant change in his/her condition; .Procedure: 1. The charge nurse will notify the resident, his/her physician, his/her legal representative, and his/her family member, when there is : .b. A change in the resident's condition in either life-threatening conditions or clinical complications;2. If the primary physician is unavailable, then contact the back-up, on call . 3. If neither physician is available, contact the medical director; 5. Except in medical emergencies, notifications will be made within 24 hours if a change in condition or status.