Every finding on record at Life Care Center of Reno

Based on observation, interview, and document review, the facility failed to ensure a sufficient number of Certified Nursing Assistants (CNAs) were scheduled to perform resident care according to the Facility Assessment (FA) for weekend shifts during January, February, March, and July 2026, resulting in excessively low weekend staffing. This deficient practice had the potential to cause delays in care and/or residents not receiving services per the residents' plan of care with the potential to result in resident falls, skin break down, and emotional distress. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated January 1, 2026 - March 31, 2026, documented the facility had excessively low weekend staffing. The Facility Assessment (FA), last revised 06/24/2024, and reviewed 06/26/2026, documented the facility required CNA coverage for each unit and shift as follows: Unit 100: -Day shift: two CNAs-Evening shift: two CNAs-Night Shift: two CNAs Unit 200: -Day shift: four CNAs-Evening shift: four CNAs-Night shift: four CNAs Unit 300:-Day shift: two CNAs-Evening shift: two CNAs-Night shift: two CNAs Unit 400: -Day shift: two CNAs-Evening shift: two CNAs-Night shift: two CNAs The FA documented the total number of CNAs needed for facility wide coverage was 10 CNAs per shift. The facility staffing schedules and time sheets for January, February, March and July 2026, documented the facility lacked adequate CNA staffing coverage during weekend shifts as follows: January: -01/03/2026: nine CNAs on evening shift, and seven CNAs on night shift. -01/04/2026: eight CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm and seven CNAs on night shift. -01/10/2026: eight CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm and nine CNAs from 6:00 pm - 10:00 pm, and 7 CNAs on night shift. -01/11/2026: eight CNAs on night shift. -01/12/2026: nine CNAs on evening shift, and eight CNAs on night shift-01/17/2026: nine CNAs on evening shift, and eight CNAs on night shift. -01/24/2026: nine CNAs on day shift, nine CNAs on evening shift, and six CNAs on night shift. -01/25/2026: nine CNAs on night shift. February -02/01/2026: eight CNAs on night shift-02/072026: nine CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm and nine CNAs from 6:00 pm - 10:00 pm, and eight CNAs on night shift. -02/08/2026: eight CNAs on night shift. -02/14/2026: nine CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm.-02/15/2026: nine CNAs on night shift. -02/21/2026: eight CNAs on day shift, seven CNAs on evening shift from 2:00 pm - 6:00 pm and eight CNAs from 6:00 pm - 10:00 pm, and nine CNAs on night shift. -02/22/2026: nine CNAs on day shift, and nine CNAs on night shift. -02/28/2026: eight CNAs on night shift. March -03/01/2026: seven CNAs on day shift, seven CNAs on evening shift from 2:00 pm - 6:00 pm and nine CNAs from 6:00 pm - 10:00 pm, eight CNAs on night shift. -03/07/2026: eight CNAs on day shift, seven CNAs on evening shift, and eight CNAs on night shift. -03/08/2026: nine CNAs on evening shift from 2:00 pm - 6:00 pm, and eight CNAs on night shift. -03/14/2026: nine CNAs on day shift, seven CNAs on evening shift, and eight on night shift. -03/15/2026: eight CNAs on day shift, nine CNAs on evening shift from 2:00 pm - 10:00 pm, and eight CNAs on night shift. -03/21/2026: nine CNAs on evening shift from 6:00 pm- 10:00 pm, and eight CNAs on night shift. -03/22/2026: eight CNAs on evening shift from 6:00 pm - 10:00 pm, and eight CNAs on night shift. -03/28/2026: nine CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm and nine CNAs from 6:00 pm - 10:00 pm, and eight CNAs on night shift. -03/29/2026: eight CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 10:00 pm, and eight CNAs on night shift. July -07/04/2026: six CNAs on night shift. -07/05/2026: eight CNAs on day shift, eight CNAs on evening shift from 2:00 pm - 6:00 pm, and eight CNAs on night shift. -07/11/2026: seven CNAs on day shift, seven CNAs on evening shift from 2:00 pm - 6:00 pm and nine CNAs from 6:00 pm - 10:00 pm, and eight CNAs on night shift. -07/12/2026: nine CNAs on evening shift from 2:00 - 6:00 pm, and nine CNAs on night shift. On 07/16/2026 at 4:11 PM, the staffing coordinator confirmed weekend staffing during January, February, March, and July 2026 was correctly and accurately documented on the facility staffing schedule and time sheets.On 07/20/2026 at 5:12 PM, the Director of Nursing (DON) confirmed during January, February, March, and July 2026, the facility had not staffed an adequate number of CNAs during the weekends per the FA.

Based on clinical record review, interview and document review, the facility failed to 1) develop a care plan addressing constipation and the use of medications for 1 of 24 sampled residents (Resident # 34) , 2) develop a care plan identifying a catheter and outlining catheter care and maintenance for 1 of 24 sampled residents (Resident #147), and 3) ensure a person-centered care plan was developed for 1 of 5 residents reviewed for unnecessary medications (Resident #1) and included the correct indication for use of psychotropic medications. This deficient practice had the potential to result in residents not receiving the care and services necessary to manage their diagnosed conditions. Findings include: Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including displaced intertrochanteric fracture of left femur, unspecified protein-calorie malnutrition, and muscle weakness (generalized). On 07/14/2026 at 9:26 AM, Resident #34 complained of not having a bowel movement for five days. Resident #34 verbalized experiencing stomach pain due to not having a bowel movement. The Medication Administration Record (MAR) for Resident #34, dated July 2026, documented the resident had the following medication ordered. Docusate Sodium capsule 100 milligram (mg) give one capsule by mouth one time a day for constipation, order date 07/14/2026. Dulcolax Suppository 10 mg (bisacodyl) insert 10 mg rectally as needed for constipation if no results from milk of magnesia daily, order date 07/02/2026. Fleet Enema 7-19 gram (gm) 118 milliliters (ml) (sodium phosphates) insert one application rectally as needed for constipation, if no results from suppository-may be given daily, ordered date 07/02/2026. Milk of Magnesia suspension 400 mg/5 ml (magnesium hydroxide) give 30 ml by mouth as needed for no bowel movement (BM) in three days may give daily, ordered date 07/02/2026. MiraLAX oral powder 17 gm/scoop (polyethylene glycol 3350) give one scoop by mouth two times a day for constipation, order date 07/14/2026. Senna tablet 8.6 mg (sennosides) give one tablet by mouth two times a day for constipation, ordered date 07/14/2026. The Comprehensive Care Plan for Resident #34 lacked a care plan addressing constipation. On 07/16/2026 at 3:44 PM, the Director of Nursing (DON) confirmed Resident's #34 care plan did not address constipation. The DON verbalized the importance of including constipation on the resident's care plan was to communicate the pharmacological interventions with the nursing staff. Resident #147 Resident #147 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, vascular dementia, and retention of urine. The Resident #147 MAR dated June 2026 document insert catheter for residual greater than 350 ml every six hours for uropathy, order date 6/30/2026 until the resident discharges. The Comprehensive Care Plan for Resident #147 lacked a care plan addressing the care and maintains of the catheter. On 07/16/2026 at 3:44 PM, the DON confirmed Resident's #147 care plan did not include the care of the catheter. The DON verbalized the importance of including the catheter on the resident's care plan was to communicate the presence and care of the catheter with the nursing staff. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including polyneuropathy, unspecified and unspecified severe protein-calorie malnutrition. An Order Summary Report for Resident #1 included the following physician orders: -Duloxetine Hydrochloride (HCl) capsule delayed release particles 20 mg. Give one capsule by mouth one time a day related to polyneuropathy, unspecified. -Remeron oral tablet 15 mg (mirtazapine). Give one tablet by mouth at bedtime related to unspecified severe protein-calorie malnutrition. A Minimum Data Set 3.0 (MDS) assessment dated [DATE], Section N, documented Resident #1 was taking antidepressant medication. Resident #1's Care Plan documented Resident #1 used antidepressant medications: Duloxetine for depression as evidenced by (aeb) verbalization of depressive thoughts and mirtazapine for depression aeb difficulty falling asleep. The date initiated was 06/16/2026. Resident #1's clinical record lacked documented evidence Resident #1 had a diagnosis of depression. On 07/20/2026 at 12:32 PM, the DON verbalized when a psychotropic medication was ordered, the DON would review the resident's clinical record and orders to ensure the medication was prescribed for an appropriate diagnosis and the diagnosis was documented in the record. The DON explained it was important to ensure a diagnosis to support prescribing the medication was documented in the record, so the facility did not administer a medication for a diagnosis the resident did not have. The DON confirmed psychotropic medications were prescribed for Resident #1. The DON verbalized Duloxetine was ordered to treat polyneuropathy and Remeron was ordered to treat severe protein-calorie malnutrition. The DON denied Resident #1 had a diagnosis of depression. The DON reviewed Resident #1's Care Plan, confirmed the Care Plan documented Resident #1 used antidepressant medications for depression and verbalized the care plan did not correctly identify the indication for the medications. The facility policy titled Psychotropic Medication Informed Consent Policy, revised 04/22/2025, documented the medical record should contain documentation of the diagnosed condition, and the behavioral (nonpharmacological) interventions attempted for which a psychotropic medication was prescribed. The facility was to update the resident's care plan and initiate behavior monitoring. The facility policy titled Area of Focus: Care Planning – Baseline, Comprehensive, and Routine Updates, reviewed 11/25/2024, documented the comprehensive care plan was to include a problem/focus statement, measurable goals, and interventions. Key tasks for developing the comprehensive care plan included identifying and collecting information needed to identify an individual's conditions and obtaining personal and medical history.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure services were provided in accordance with professional standards when a Registered Nurse (RN) did not follow safe medication administration practices. The RN administered insulin to a resident using another resident's insulin injector pen for one unsampled resident (Resident #35), and a resident (Resident #176) received prescribed insulin more than three hours late. These failures to follow accepted nursing standards and the Nevada Nurse Practice Act had the potential to expose residents to cross contamination with pathogens and to cause adverse symptoms related to delayed insulin administration.Findings include: Resident #176Resident #176 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, type two diabetes mellitus with other specified complication, and long term (current) use of insulin.A physician order for Resident #176 dated [DATE], documented insulin glargine solution 100 units (u)/milliliter (ml), inject 18 units subcutaneously one time a day for diabetes.Resident #176's Medication Administration Record (MAR) documented the resident was to receive the insulin glargine injection at 8:00 PMResident #35Resident #35 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and long term (current) use of insulin.A physician order for Resident #35 dated [DATE], documented insulin glargine solution 100 u/ml, inject 10 units subcutaneously one time a day for diabetes.Resident #35's MAR documented the resident was to receive the insulin glargine injection at 8:00 AM.On [DATE] at 8:09 AM, an RN administered a blue colored insulin injection pen to Resident #35 while the state surveyor observed from the doorway of the resident's room. The state surveyor was not able to verify the insulin injection pen prior to administration. The RN then exited the resident's room and returned to the medication cart while holding the insulin injection pen and attempted to place the insulin injection pen into the medication cart.On [DATE] at 8:13 AM, the injection pen was observed to have Resident #176's name affixed by label to the insulin glargine 100 u/ml injection pen. On [DATE] at 8:21 AM, the RN confirmed the RN knew the insulin glargine injector pen belonged to Resident #176 when the RN administered the insulin glargine to Resident #35. The RN verbalized administering 10 units of insulin glargine to Resident #35 from Resident #176's insulin glargine pen because the insulin glargine pen for Resident #35 was not available. The RN explained the RN did not think using Resident #176's insulin glargine pen for Resident #35 was a problem since the insulin was the same type and strength and the pen was new.The RN explained the RN could have retrieved another insulin glargine injector pen from the facility's automated pharmacy dispensing system device (Omnicell) but had not. The RN verbalized the use of another resident's insulin glargine pen was easier and faster than going to the Omnicell and retrieving a new insulin glargine pen for Resident #35. The RN communicated the use of an insulin injection pen belonging to another resident put the residents at risk for infection and understood it was not the correct medication administration procedure.On [DATE] at 8:49 AM, the Assistant Director of Nursing (ADON) explained when a medication was missing from the medication cart the process would be to retrieve another insulin injection pen from the Omnicell, check the medication room refrigerator, or call the pharmacy to get another injection pen. The ADON verbalized the use of another resident's pen was not the correct process, would place the resident at risk of using an expired or contaminated injection pen, and the insulin strength could be different from resident to resident. On [DATE] at 9:18 AM, the Director of Nursing (DON) communicated it was not acceptable for a nurse to use another resident's insulin injection pen was not available. The DON confirmed the Omnicell would have a replacement insulin injection pen available and expected nursing staff to follow the 10 Rights of Medication Administration at all times.On [DATE] at 6:49 PM, the DON communicated the performance of an audit had been conducted of resident injectable insulin pens the RN had administered during the day. All of the injectable insulin pens would be replaced since the facility did not know if the RN had administered to insulin dependent residents with the correct injectable insulin pen. Resident #176's MAR dated [DATE]-[DATE], documented the resident did not receive the 8:00 PM insulin glargine injected dose until 11:51 PM on [DATE].On [DATE] at 3:15 PM, the DON confirmed Resident #176 did not receive the 8:00 PM insulin glargine dose until 11:51 PM on [DATE], because the night shift nurse had to get supervisory approval for the pharmacy to fill another insulin glargine injection pen due to the pen's absence from the medication cart. The DON confirmed the insulin glargine injectable pen was not available in the medication cart for Resident #176 because all of the insulin injectable pens had been disposed of after completing the audit on [DATE]. On [DATE] at 5:08 PM, the DON confirmed the nurses were taught insulin was a high-alert, high-risk medication and required careful documentation and observation.A facility document titled The 10 Rights of Medication Administration, undated, documented the 10 rights would be followed every time and was a vital checklist used by healthcare professionals to prevent errors and ensure patient safety. The 10 rights included:1-Right Patient: Verified resident identity with at least two identifiers, such as name and date of birth , before giving any medications.2-Right Medication: Confirmed the drug label perfectly matched the prescriber's order.3-Right Dose: Ensured the amount was accurate and matched the prescribed order.4-Right Route: Administered the medication via the correct method (oral, subcutaneous).5-Right Time/Frequency: Gave the medication at the proper time interval and frequency.6-Right Reason: Understood why the medication was prescribed to the resident.7-Right Assessment: Completed any necessary pre-administration assessments.8-Right Education: Informed the resident of the medication's purpose, potential side effects, and administration instructions.9-Right to Refuse: Acknowledged the resident's legal and ethical right to decline the medication.10-Right Documentation: Accurately recorded the drug, dose, time, route, and resident response immediately after administration.The facility policy titled Administration of Medications, dated [DATE], documented the facility would ensure medications were administered safely and appropriately. A significant medication error was one which caused the resident discomfort or jeopardized resident health and safety. Accepted professional standards and principles applied to professionals providing services and included the various practice regulations in each state.The facility policy titled Insulin Pen Use, dated [DATE], documented insulin pens were for single-resident use only and should never be shared among residents. Insulin was considered a high-alert medication because it could cause significant resident harm when used in error. Insulin cartridges could become contaminated with bloodborne pathogens. The medication label would be compared to the order in the resident's medical record and the resident's identity would be confirmed using at least two resident identifiers.A Centers for Disease Control and Prevention (CDC) hand out titled What Every Healthcare Provider Needs to Know, undated, documented sharing insulin pens and other injection equipment harmed residents by placing residents at risk of bloodborne and bacterial pathogen transmission. Injection equipment, including insulin pens, needles, and syringes, should never be used for more than one person.The RN Unit Registered Nurse Job Description, signed and dated by the RN on [DATE], documented the RN would deliver quality nursing care to residents and provide the care and services to assure resident safety in accordance with all applicable laws and regulations. The RN must have expert knowledge in the field of practice, possess the ability to make independent decisions, be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing nursing functions, competently deliver quality nursing care to residents, and be able to use reasoning skills and good judgement.The Nurse Practice Act Nevada Administrative Code (NAC) 632.212 Duties included; competency required, documented the Board would interpret the practice of professional and competent nursing to include the following duties: exercise sound judgement, make decisions, administer medication which were properly authorized, determine the necessity and appropriateness of heath care services for a patient, and maintain accountability in the delegation of care. Cross referenced with F880.

Based on observation, interview, clinical record review and document review, the facility failed to ensure interventions to prevent accidents were implemented when fall mats were not placed next a resident's bed as ordered by the physician and as documented in the resident's care plan for 1 of 24 sampled residents (Resident #20). This deficient practice had the potential to result in residents suffering injuries from falls including abrasions and fractures. Findings include:Resident #20Resident #20 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and muscle weakness (generalized).On 07/13/2026 at 2:50 PM, Resident #20 was lying in the resident's bed. A soft, padded helmet was on the resident's bedside table. Resident #20 verbalized the resident wore the helmet due to the resident experiencing multiple falls. The resident recalled the resident hit the resident's head during a previous fall and denied the resident knew when the most recent fall occurred. Fall mats were not present on the floor next to the resident's bed.A Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented Resident #20 had one fall with no injury and one fall with injury (except major) since admission/entry/reentry or prior assessment.A Fall Risk Evaluation dated 07/06/2026, documented a score of 22. A Fall Risk Evaluation dated 07/09/2026, documented a score of 20. An Assessment Outcome report for fall risk evaluations documented interventions should have been initiated for scores of ten or above. Resident #20's Care Plan documented the following:-Resident #20 was at risk for falls. Interventions included: assisting with activities of daily living as needed, call light within reach, complete fall risk assessment, and orient resident to room. The date initiated was 06/25/2026.-Resident #20 had an actual fall with minor injury, poor balance, poor communication/comprehension, and unsteady gait. The date initiated was 07/02/2026. Interventions included but were not limited to floor mats placed side of bed and low bed to prevent serious injury from falls. The date initiated for the interventions was 07/09/2026.A Physician Progress Note dated 07/06/2026, documented Resident #20 had a fall the previous night. No head strike, joint pain, or obvious contusion. The resident had no memory of the event. Close watch. Will place mats, low bed.An Order Summary Report for Resident #20 documented mats at bedside, low bed one time a day for fall risk. The order date was 07/06/2026.On 07/15/2026 at 10:20 AM, Resident #20 was lying in the resident's bed. Fall mats were not present on the floor next to the resident's bed.On 07/15/2026 at 10:40 AM, a Licensed Practical Nurse (LPN) verbalized the facility implemented several interventions to prevent residents from falling including ensuring residents had their call lights and educating the residents to call for assistance, ensuring residents wore non-skid socks/footwear, and lowering the bed for safety. The LPN recalled Resident #20 had a fall approximately one month prior. The resident hit the resident's head and was sent to the emergency room for evaluation; however, the resident was not admitted to the hospital. Upon return to the facility, interventions implemented to help prevent additional falls and to prevent injuries from falls included making sure the resident's soft/padded helmet was on when the resident was out of bed, and the bed was in the lowest position when in bed. The LPN denied fall mats were currently in use for Resident #20 and denied the LPN could recall Resident #20 having fall mats in place previously.On 07/15/2026 at 10:48 AM, the LPN entered Resident #20's room and confirmed fall mats were not in place next to the resident's bed.On 07/15/2026 at 12:40 PM, the Director of Nursing (DON) verbalized staff knew what interventions were necessary for each resident to help prevent falls and prevent injuries from falls by communicating residents' needs during shift-to-shift report and by reviewing physician orders and care plans. If a resident was a high fall risk and required specific interventions, the interventions would be documented in the care plan.The DON verbalized Resident #20 had an unwitnessed fall on 07/09/2026. The DON reviewed Resident #20's clinical record and confirmed fall mats should have been in use. The DON explained staff's failure to utilize a fall mat when indicated could result in increased injuries if the resident hit the floor such as broken bones and abrasions.The facility policy titled Area of Focus: Fall Management, reviewed 12/03/2025, documented the facility would assess the resident upon admission/readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment. During the admission and readmission process, a care plan would be developed and initiated by the admitting nurse on any residents assessed to be at risk for falls. The care plan would be reviewed and revised, if indicated, upon completion of each comprehensive, significant change and quarterly MDS assessment, upon a fall event and as needed thereafter.

Based on observation, document review and interview, the facility failed to ensure: 1) a kitchen floor drain was maintained free of food debris, and 2) a kitchen stovetop was free of grease and grime. This deficient practice had the potential to increase the risk of cross-contamination and result in foodborne illness and infection for residents.Findings include:On 07/13/2026 at 9:09 AM, observation of the kitchen dish sink area revealed a floor drain containing accumulated food debris.During an interview at the time of the observation, the Dietary Services Manager (DSM) confirmed the floor drain contained food debris and stated it should be clean and free of debris.On 07/13/2026 at 9:19 AM, observation of the stovetop in the [NAME] building kitchen revealed an accumulation of grease and grime.During an interview at the time of the observation, the DSM confirmed the stovetop had an accumulation of grease and grime and stated, It looks like it has been in excess of one week since it was cleaned.On 07/16/2026 at 9:59 AM, the DSM verbalized the food debris in the floor drain and the accumulation of grease and grime on the stovetop could promote bacterial growth, creating a potential source of cross-contamination and increasing the risk of infection.On 07/16/2026 at 10:23 AM, the Dietitian confirmed the food debris in the floor drain and the accumulation of grease and grime on the stovetop had the potential to contribute to cross-contamination and increase the risk of infection and foodborne illness. The Dietitian further stated that maintaining the areas in a clean and sanitary condition was essential for effective infection prevention and control.The facility policy titled Food Safety, revised 05/26/2026, documented cross-contamination was the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges or utensils which were not cleaned.

Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) an indwelling urinary catheter drainage bag was not resting on the floor for 1 of 24 sampled residents (Resident #20), 2) a staff member performed hand hygiene between glove changes while providing wound care during a wound care observation for one unsampled resident (Resident #127), and 3) a Registered Nurse (RN) did not inject a resident with another resident's insulin glargine injectable pen for one unsampled resident (Resident #35). This deficient practice had the potential to result in a resident developing an infection from a resident's indwelling medical device coming into contact with a potentially contaminated surface and a staff member's lack of hand hygiene, and had the potential to place residents at risk of cross-contamination with blood-borne pathogens and bacteria after an insulin pen was administered to the wrong resident.Findings include: Medication Error Resident #176 Resident #176 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, type two diabetes mellitus with other specified complication, and long term (current) use of insulin. A physician order for Resident #176 dated 07/14/2026, documented insulin glargine solution 100 units (u)/milliliter (ml), inject 18 units subcutaneously one time a day for diabetes. Resident #35 Resident #35 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and long term (current) use of insulin. A physician order for Resident #35 dated 04/30/2026, documented insulin glargine solution 100 u/ml, inject 10 units subcutaneously one time a day for diabetes. On 07/15/2026 at 8:09 AM, a Registered Nurse (RN) was administered an insulin injection pen to Resident #35 while the state surveyor observed from the doorway of the resident's room. The state surveyor was not able to verify the insulin injection pen prior to administration. The RN then exited the resident's room and returned to the medication cart while holding the insulin injection pen and attempted to place the insulin injection pen into the medication cart. The RN verbalized the RN was going to place the insulin glargine injector pen back into the medication cart. On 07/15/2026 at 8:13 AM, the injection pen was observed to have Resident #176's name affixed by label to the insulin glargine injection pen. On 07/15/2026 at 8:21 AM, the RN confirmed the RN knew the insulin glargine injector pen belonged to Resident #176 when the RN administered the insulin glargine to Resident #35. The RN verbalized administering 10 units of insulin glargine to Resident #35 from Resident #176's insulin glargine pen because the insulin glargine pen for Resident #35 was not available. The RN explained the RN did not think using Resident #176's insulin glargine pen for Resident #35 was a problem since the insulin was the same type and strength and the pen was new. The RN explained the RN could have retrieved another insulin glargine injector pen from the facility's automated pharmacy dispensing system device (Omnicell) but had not. The RN verbalized the use of another resident's insulin glargine pen was easier and faster than going to the Omnicell and retrieving a new insulin glargine pen for Resident #35. The RN communicated the use of an insulin injection pen belonging to another resident put the residents at risk for infection and understood it was not the correct medication administration procedure. On 07/15/2026 at 8:49 AM, the Assistant Director of Nursing (ADON) verbalized the use of another resident's insulin injectable pen was not the correct process for a missing medication on the medication cart and would place the resident at risk of using a contaminated injection pen. On 07/15/2026 at 9:18 AM, the Director of Nursing (DON) communicated it was not acceptable for a nurse to use another resident's insulin injection pen was not available. The DON explained the use of another resident's injectable insulin pen could cause cross-contamination of pathogens between the residents. The facility policy titled Administration of Medications, dated 05/06/2022, documented the facility would ensure medications were administered safely and appropriately. The facility policy titled Insulin Pen Use, dated 05/19/2025, documented insulin pens were for single-resident use only and should never be shared among residents. A Centers for Disease Control and Prevention (CDC) hand out titled What Every Healthcare Provider Needs to Know, undated, documented sharing insulin pens and other injection equipment harmed residents by placing residents at risk of bloodborne and bacterial pathogen transmission. Injection equipment, including insulin pens, needles, and syringes, should never be used for more than one person. A facility document titled The 10 Rights of Medication Administration, undated, documented the 10 rights must be followed every time and was a vital checklist used by healthcare professionals to prevent errors and ensure patient safety. Urinary catheter drainage bag on the floor Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and personal history of urinary tract infections. A Physician's Order dated 07/03/2026, documented indwelling catheter to straight drainage. Size: 16 French (Fr). Bulb: 10 milliliters (ml). Change for infection, obstruction or when the closed system is compromised as needed for neurogenic bladder. On 07/15/2026 at 10:20 AM, Resident #20 was lying in the resident's bed. The resident's urinary catheter drainage bag was hung on the bed frame with the lower portion of the bag lying on the floor. On 07/15/2026 at 10:28 AM, a Certified Nursing Assistant (CNA) knocked on Resident #20's door, entered the resident's room, and shut the door. On 07/15/2026 at 10:30 AM, the CNA exited Resident #20's room. The CNA verbalized when a resident had a urinary catheter, staff would hook the bag on the resident's bed, so the drainage bag was not touching the floor. The CNA explained it was important to keep the drainage bag off the floor due to the risk of contamination of the bag. On 07/15/2026 at 10:39 AM, the CNA confirmed Resident #20 had an indwelling urinary catheter. The CNA entered Resident #20's room and confirmed the resident's catheter drainage bag was touching the floor. On 07/15/2026 at 12:40 PM, the Director of Nursing (DON) verbalized urinary catheter drainage bags were to be placed below the level of the bladder and could not be on the floor. It was important to keep the drainage bag off the floor to help prevent infection. On 07/16/2026 at 3:37 PM, the Infection Preventionist (IP) verbalized it was never appropriate for a urinary catheter drainage bag to be touching the floor. It was important to keep the bag off the floor because bacteria traveled from the ground up and it could cause a urinary tract infection. The facility policy titled Indwelling Urinary Catheter (Foley) Management, reviewed 09/10/2024, documented general urinary catheter maintenance guidelines included maintaining unobstructed urine flow, keeping the collecting bag below the level of bladder at all times and not resting the bag on the floor. The facility document titled Indwelling Urinary Catheter (Foley) Care and Management, reviewed 09/09/2025, documented to not place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infection (CAUTI). Hand Hygiene Resident #127 Resident #127 was admitted to the facility on [DATE], with a diagnosis of displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing. An Order Summary Report for Resident #127 documented wound care: right medial malleolus surgical incision – cleanse with normal saline, pat dry, apply Xeroform (a petrolatum gauze dressing), cover with clean dry dressing every Tuesday, Thursday, Saturday and as needed. The order start date was 07/09/2026. On 07/16/2026 at 1:25 PM, the Wound Care Nurse (WCN) entered Resident #127's room. The following occurred in sequential order: the WCN donned an isolation gown and gloves, cleared off the resident's bedside table including removal of the resident's urinal, doffed the gloves and donned new gloves without performing hand hygiene, wiped the bedside table with a bleach wipe, doffed the pair of gloves, laid a clean towel over the bedside table, donned new gloves, removed a sock and compression wrap from the resident's right lower leg, doffed the gloves and donned new gloves without performing hand hygiene, removed the current dressing from the resident's right medial malleolus and doffed the pair of gloves. On 07/16/2026 at 1:30 PM, the WCN washed the WCN's hands with soap and water at the sink in the resident's room, donned a new pair of clean gloves and touched the resident's leg while educating the resident on signs and symptoms of infection. On 07/16/2026 at 1:34 PM, the WCN doffed the pair of gloves and donned new gloves without performing hand hygiene, touched the resident's foot, doffed the gloves and donned new gloves without performing hand hygiene, cleansed the resident's wound with normal saline and dry gauze, applied Xeroform to the wound, doffed the gloves and donned new gloves without performing hand hygiene, opened and applied a new border gauze dressing, wrapped the resident's right foot and lower leg with a compression wrap and reapplied the resident's sock. On 07/16/2026 at 1:48 PM, the WCN verbalized it was the WCN's usual practice to apply hand sanitizer (alcohol-based hand rub) to the WCN's hands between glove changes. The WCN confirmed the WCN did not perform hand hygiene between each glove change while providing wound care to Resident #127. On 07/16/2026 at 3:37 PM, the IP verbalized hand hygiene was expected to be performed by staff any time the staff member entered or exited a resident's room, touched something contaminated, or when the staff member dropped something on the floor. The IP confirmed hand hygiene should have been performed between glove changes and verbalized hand hygiene was important to help prevent transfer of potential contaminants to the staff member's hands and onto the new gloves. The facility policy titled Hand Hygiene, reviewed 06/01/2026, documented staff were to perform hand hygiene (even if gloves were used) before and after contact with residents, after contact with objects and surfaces in the resident's environment, after removing personal protective equipment (e.g., gloves, gown, eye protection), and before performing a procedure such as an aseptic task (e.g., dressing care).

Based on observation and interview, the facility failed to maintain essential kitchen equipment in good repair. This deficient practice had the potential to compromise the sanitary condition of dishwashing equipment and increase the risk of contamination of dishes and utensils used for resident meal service.On 07/13/2026 at 9:11 AM, with the Dietary Services Manager (DSM) present, the following was observed:The kitchen dishwasher had water pipes with corrosive white mineral buildup on the exterior surfaces and appeared to be leaking. The DSM acknowledged the mineral buildup at the time of the observation and confirmed the dishwasher appeared to be leaking. The DSM stated the equipment should be maintained in good repair.On 07/16/2026 at 9:59 AM, the DSM confirmed there was a corrosive white mineral buildup on the exterior surfaces of the dishwasher pipes and the dishwasher appeared to be leaking. The DSM verbalized the dishwasher had not been maintained in good repair and the leaking equipment could create conditions conducive to bacterial growth, increasing the risk of cross-contamination and infection. The facility was not able to produce a policy related to risk of contamination associated with kitchen equipment not maintained in good repair.

Resident #229 Resident #229 was admitted to the facility on [DATE], with a diagnosis of encounter for surgical aftercare following surgery on the digestive system. Resident #229's clinical record documented the resident was moved to a different room in the facility on 02/19/2025 and on 02/21/2025. A Room Change Notification form dated 02/19/2025, documented Resident #229 was moved from room [ROOM NUMBER]-1 to 208-1. The reason for the room change was documented as resident request. The form was signed by the resident. A Diet Order and Communication form dated 02/21/2025, included a handwritten checkbox labeled Room Change. The form lacked documentation related to the reason for the room change, the resident being informed prior to the room change, and a signature from the resident. The resident's clinical record lacked any additional documentation related to the room change on 02/21/2025. On 06/30/2025 at 12:48 PM, the Administrator verbalized the Administrator was unsure of the reason for Resident #229's room change on 02/21/2025 and would have to look into it. On 06/30/2025 at 1:29 PM, the Administrator explained Resident #229 was moved to room [ROOM NUMBER] on 02/21/2025 to allow the resident to be in a private/single occupancy room. The Administrator was unable to provide documentation Resident #229 received written notice, including the reason for the change, prior to the 02/21/2025 room change. The facility policy titled, Resident Room Relocation, reviewed 09/05/2024, documented Residents had the right to receive written notice, including the reason for the change, before the resident's room in the facility was changed. Cross reference with F745. Based on clinical record review, interview, and document review, the facility failed to provide written notice, including the reason for a room change, to 37 of 49 residents (Residents #71, #56, #72, #83, #75, #372, #271, #85, #222, #88, #370, #78, #20, #65, #6, #32, #38, #33, #375, #223, #41, #376, #79, #35, #27, #44, #96, #275, #34, #227, #175, #177, #2, #377, #25, #91, and #171) who were relocated within the facility and 1 of 4 discharged residents reviewed (Resident #229). The widespread deficient practice had the potential to result in, more than minimal psychosocial harm to affected residents, and reflects a systemic issue. Findings include: The Resident Listing Report dated 06/22/2025, identified the following current residents with a room change from August 2024 through June 2025: -Resident #71 changed rooms on 09/12/2025. -Resident #56 changed rooms on 02/14/2025. -Resident #72 changed rooms on 05/28/2025. -Resident #83 changed rooms on 05/02/2025. -Resident #75 changed rooms on 04/04/2025. -Resident #372 changed rooms on 04/10/2025. -Resident #271 changed rooms on 01/05/2025. -Resident #85 changed rooms on 05/12/2025. -Resident #222 changed rooms on 05/06/2025. -Resident #88 changed rooms on 06/25/2025. -Resident #370 changed rooms on 02/21/2025. -Resident #78 changed rooms on 12/06/2024. -Resident #20 changed rooms on 06/09/2025. -Resident #65 changed rooms on 05/29/2025. -Resident #6 changed rooms on 02/23/2025. -Resident #32 changed rooms on 04/24/2025. -Resident #38 changed rooms on 06/06/2025. -Resident #33 changed rooms on 06/13/2025. -Resident #375 changed rooms on 06/10/2025. -Resident #223 changed rooms on 04/10/2025. -Resident #41 changed rooms on 04/28/2025. -Resident #376 changed rooms on 06/16/2025. -Resident #79 changed rooms on 06/09/2025. -Resident #35 changed rooms on 11/25/2024. -Resident #27 changed rooms on 01/08/2025. -Resident #44 changed rooms on 06/17/2025. -Resident #96 changed rooms on 05/30/2025. -Resident #275 changed rooms on 06/17/2025. -Resident #34 changed rooms on 02/19/2025. -Resident #227 changed rooms on 06/23/2025. -Resident #175 changed rooms on 10/16/2024. -Resident #177 changed rooms on 06/05/2025. -Resident #2 changed rooms on 05/27/2025. -Resident #377 changed rooms on 06/16/2025. -Resident #25 changed rooms on 05/07/2025. -Resident #91 changed rooms on 06/19/2025. -Resident #171 changed rooms on 06/19/2025. Resident #71 Resident #71 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Resident #56 Resident #56 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing. Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Resident #83 Resident #83 was admitted to the facility on [DATE], with a primary diagnosis of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side. Resident #75 Resident #75 was admitted to the facility on [DATE], with a primary diagnosis of displaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing. Resident #372 Resident #372's was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute pyelonephritis. Resident #271 Resident #271 was admitted to the facility on [DATE], with a primary diagnosis of alcoholic polyneuropathy. Resident #85 Resident #85 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation. Resident #222 Resident #222 was admitted to the facility on [DATE], with a primary diagnosis of displaced fracture of greater trochanter of left femur initial encounter for open fracture Resident #88 Resident #88 was admitted to the facility on [DATE], with a primary diagnosis of acute eosinophilic pneumonia. Resident #370 Resident #370 was admitted to the facility on [DATE], with a primary diagnosis of enterocolitis due to clostridium difficile not specified as recurrent. Resident #78 Resident #78 was admitted to the facility on [DATE], with a primary diagnosis of acute respiratory failure with hypoxia. Resident #20 Resident #20 was admitted to the facility on [DATE], with a primary diagnosis of acute and chronic respiratory failure with hypoxia. Resident #65 Resident #65 was admitted to the facility on [DATE], with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of other fracture of right femur, initial encounter for closed fracture. Resident #32 Resident #32 was admitted to the facility on [DATE], with a primary diagnosis of aftercare following joint replacement surgery. Resident #38 Resident #38 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute pyelonephritis. Resident #33 Resident #33 was admitted to the facility on [DATE], with a primary diagnosis of fracture of unspecified part of the neck of right femur, subsequent encounter for closed fracture with routine healing. Resident #375 Resident #375 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Resident #223 Resident #223 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Resident #41 Resident #41 was admitted to the facility on [DATE], with a primary diagnosis of acute and chronic respiratory failure with hypoxia. Resident #376 Resident #376 was admitted to the facility on [DATE], with a primary diagnosis of pneumonia, unspecified organism. Resident #79 Resident #79 was admitted to the facility on [DATE], with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident #35 Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of other sequelae of cerebral infarction. Resident #27 Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of metabolic encephalopathy. Resident #44 Resident #44 was admitted to the facility on [DATE], with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication. Resident #96 Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of unspecified atrial fibrillation. Resident #275 Resident #275 was admitted to the facility on [DATE], with a primary diagnosis of encounter for surgical aftercare following surgery on the nervous system. Resident #34 Resident #34 was admitted to the facility on [DATE], with a primary diagnosis of cerebral infarction due to embolism of left middle cerebral artery. Resident #227 Resident #227 was admitted to the facility on [DATE], and readmitted on /28/2025, with a primary diagnosis of unspecified intracapsular fracture of right femur, subsequent encounter for closed fracture with routine healing. Resident #175 Resident #175 was admitted to the facility on [DATE], with a primary diagnosis of zoster without complications. Resident #177 Resident #177 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of urinary tract infection, site not specified. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of unspecified fracture of right acetabulum, subsequent encounter for fracture with routing healing. Resident #377 Resident #377 was admitted to the facility on [DATE], with a primary diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. Resident #25 Resident #25 was admitted to the facility on [DATE], with a primary diagnosis of chronic respiratory failure with hypoxia. Resident #91 Resident #91 was admitted to the facility on [DATE], with a primary diagnosis of neutropenia, unspecified. Resident #171 Resident #171 was admitted to the facility on [DATE], with a primary diagnosis of unspecified nondisplaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing. On 06/23/2025 at 9:33 AM, Resident #171 verbalized approximately five days prior, the resident was evicted from their previous room in the 400 unit of an adjacent building within the same facility. The resident was told by facility staff not to speak to Resident #171's roommate and when they continued to speak, Resident #171 was moved to their new room. Resident #171 verbalized the resident did not want to move rooms as the resident liked their previous roommate. Room Change Notification Forms were provided for the following residents identified in the Resident Listing Report, however lacked documentation of the reason for the room changes: Residents #71, #88, #375, #223, #376, #79, #34, #227, #177, #377, and #91. The following clinical records lacked documented evidence of a room change notification completed prior to the room changes identified in the Resident Listing Report: Residents #56, #72, #83, #75, #372, #271, #85, #222, #370, #78, #20, #65, #6, #32, #38, #33, #41, #35, #27, #44, #96, #275, #175, #2, #25, and #171. On 06/25/2025 at 1:58 PM, the Licensed Social Worker (LSW) verbalized room change notifications were important because residents had the right to decide to change rooms. On 06/25/2025 at 1:58 PM, the Director of Nursing (DON) verbalized room change notifications were expected to be completed prior to every room change. The DON confirmed Resident #171's clinical record lacked documented evidence of a room change notification for the 06/19/2025 room change. The DON explained the lack of room change notifications was a pervasive issue in the facility. On 06/30/2025 at 1:00 PM, the Medical Director (MD) explained prior to the room change, Resident #171 and their previous roommate discussed their medications and other healthcare needs. Resident #171 attempted to direct the roommate's care, leading to frustration from facility staff and Resident #171. The MD verbalized to mitigate the privacy risk and address the personality conflicts between Resident #171 and the staff responsible for the room in the 400 unit, the facility requested Resident #171 move to a private room. On 06/26/2025 at 9:54 AM, the Administrator verbalized all residents with a room change should have a room change notification with a reason for room change documented. On 06/26/2025 at 9:54 AM, the Administrator verbalized all residents with a room change should have a room change notification with a reason for room change documented. The Administrator confirmed the aforementioned residents lacked room change notifications with the reason for room change prior to changing rooms.

Based on observation, interview, and document review, the facility failed to ensure 1) handwashing stations were in working order and stocked with soap and disposable gloves, 2) dry food was sanitarily stored, 3) a griddle's grease trap was maintained in clean working condition, and 4) a refrigerator was monitored for safe storage temperatures. This deficient practice had the potential to affect all residents in the facility by increasing the risk of infection and foodborne illnesses. Findings include: Kitchen Handwashing Station On 06/22/2025 at 11:37 PM, the faucet controls of a hand sink in the primary kitchen dish room were in an active position; however, there was no water flow. On 06/22/2025 at 11:37 PM, the Registered Dietician (RD) verbalized being unaware the hand sink was out of order and confirmed there was no water flow. The RD explained it was important hand sinks were in working order because staff must be able to sanitize their hands in a food prep environment. On 06/26/2025 at 2:19 PM, the handwashing station in the café/gift shop was not stocked with soap and disposable hand towels. On 06/26/2025 at 2:19 PM, the Dietary Manager (DM) confirmed there were no hand towels at the café/gift shop handwashing station. On 06/26/2025 at 3:01 PM, a Certified Nursing Assistant (CNA) responsible for overseeing the café/gift shop confirmed there was no hand soap present at the café/gift shop handwashing station. The facility policy titled, Safe Food Handling, revised 04/30/2025, documented associates would wash their hands in a handwashing sink in accordance with current food code guidelines immediately before work in the morning, after eating or drinking, during food preparation, before donning gloves, and after engaging in any other activities to contaminate hands. The United States Food and Drug Administration 2022 Food Code, dated 01/23/2023, documented each handwashing sink would be provided with a hand cleaning liquid powder or bar soap and individual disposable towels or other hand drying device. Dry Food Storage On 06/22/2025 at 11:41 AM, a scoop was placed in a transparent lidded bin of rice cereal with the handle in contact with the cereal food. On 06/22/2025 at 11:414 AM, the RD confirmed the scoop was inside the bin with the handle touching the rice cereal. The RD verbalized the scoop should not be in the bin as it risked contamination of the food. On 06/26/2025 at 2:19 PM, the DM verbalized food scoops should have place holders. The facility policy titled, Food Safety, reviewed 05/01/2025, documented scoops would be stored in a manner to prevent contamination of food ingredients. Scoops would be stored outside of bins or placed in a holder on the side of the bin. Grease Trap On 06/22/2025 at 11:43 AM, charred grease was spread over the entire surface of the primary kitchen's griddle grease trap. On 06/22/2025 at 11:43 AM, a [NAME] confirmed the grease trap was covered in charred grease. The [NAME] explained it was important to clean the grease trap often to prevent the grease from catching fire. The [NAME] verbalized cleaning the grease trap once a week. On 06/22/205 at 11:43 AM, the RD confirmed the grease trap was covered in grease and verbalized being unsure how often they were meant to be cleaned. On 06/26/2025 at 2:08 PM, the DM verbalized the grease traps should be cleaned once a week or more often depending on the grease buildup. The DM verbalized the facility did not keep a cleaning log for the griddle grease trap. The facility policy titled, Safe Food Handling, revised 04/30/2025, documented all work surfaces, utensils and equipment were cleaned and sanitized appropriately after each use and if contaminated. Refrigerator Log On 06/26/2025 at 3:01 PM, the café/gift shop refrigerator lacked a temperature log. On 06/26/2025 at 3:01 PM, the CNA responsible for overseeing the café/gift shop verbalized the facility had not yet begun monitoring the refrigerator as the café/gift shop was recently opened approximately two weeks prior. The CNA confirmed residents were served out of the café/gift shop and explained it was important to monitor the refrigerator temperatures to ensure temperature consistency when serving drinks to the residents. On 06/30/2025, the DM verbalized refrigerator temperatures should be documented in the morning prior to opening the kitchen and at night prior to closing the kitchen. The DM explained temperature logs helped to ensure the refrigerator was running at a temperature to keep the food inside fresh. The facility policy titled, Gift Shop Operation, reviewed 05/15/2025, documented snack shops would conform to all regulations relating to sanitation, refrigeration, food quality, and other rules relative to general dietary and kitchen services. The facility policy titled, Food Safety, reviewed 05/01/2025, documented refrigerator temperatures were recorded at least twice daily on the refrigerator temperature log using an inside thermometer.

Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the facility had a process for written notification of resident room changes and the facility's influenza (flu) and pneumonia (PNA) vaccination program included 1) screening residents for eligibility to receive the vaccines, 2) the provision of education related to the risk and benefits of the vaccines to residents and/or the resident's representative preventing the resident or the resident's representative from making an informed decision regarding the vaccines, 3) a process for determining/selecting the correct PNA vaccine for each resident per the Centers for Disease Control and Prevention (CDC) guidance. This failure resulted in substandard quality of care. Findings include: Room Changes The facility lacked documented evidence 38 of 49 residents who experienced a room change while residing in the facility received written documentation of the reason for the room change was provided to the resident or the resident's representative. Influenza Vaccine The facility lacked documented evidence 38 of 38 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2024/2025 flu vaccines was provided to the resident or the resident's representative. Pneumonia Vaccine The facility lacked documented evidence 38 of 38 residents eligible or potentially eligible to receive a PNA vaccine were screened for eligibility to receive a PNA vaccine and lacked documented evidence education regarding the PNA vaccine the resident was eligible to receive was provided to the resident or the resident's representative. On 07/01/2025 at 1:47 PM, the Administrator explained the facility had identified issues regarding resident notification of room changes and resident influenza and pneumonia vaccines. The Administrator explained the process put in place for written notification of resident room changes was still being actively monitored and confirmed there were still ongoing issues with the notification of resident room changes. The Administrator verbalized the facility had no current action plan implemented for resident influenza and pneumonia vaccinations. The Executive Directors job description, signed and dated 7/15/2024 by the Administrator, documented the Executive Director provides leadership and direction over all facility operations to provide quality patient care in accordance with all laws, regulation and facility standards. Cross Reference with tags F559 and F883

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure corrective action was implemented to address identified problems related to the lack of screening and education for influenza and pneumococcal vaccinations. This deficient practice had the potential to result in the exposure of all residents, staff and visitors to harmful infectious agents. Findings include: On 07/01/2025 at 1:47 PM, during the QAPI review with the Administrator, the Administrator verbalized the facility had identified a concern related to the lack of screening and education for influenza and pneumococcal vaccinations. The Administrator confirmed no corrective action had been put in place related to the screening and education provided for influenza and pneumococcal vaccinations. The facility policy titled Area of Focus: QAA and QAPI Program, reviewed 11/20/2024, documented the Quality Assessment and Assurance (QAA) committee responsibilities included identifying and responding to quality deficiencies throughout the facility. Cross reference with F883.

Based on observation, clinical record review, document review, and interview, the facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) Committee failed to identify, develop and implement plans of action for systemic issues related to resident room changes and the facility bowel and bladder program. Findings include: Room Changes On 07/01/2025 at 1:47 PM, the Administrator verbalized QAPI had identified and developed a plan for resident room changes. The Administrator verbalized the QAPI Committee began working on resident notifications of room changes in May 2025, and was still be monitored. The Administrator confirmed the corrective action should have been revised when identification of the notification sheets were not completed with room change reasons. Bowel and Bladder Program On 07/01/2025 at 1:47 PM, the Administrator confirmed the QAPI Committee had identified and developed a plan for the facilities bowel and bladder program, ensuring staff were rounding on residents every two hours. The Administrator verbalized this was an ongoing Performance Improvement Project, and the QAPI committee agreed the bowel and bladder program only required to include two-hour resident and bed checks. The facility's Quality Assurance Performance Improvement (QAPI) Plan revised January 2025, documented the facility was committed to being the premier provider of long term health care in America. The facility programs, services and facilities must be designed and operated with superior quality to satisfy the needs of the residents. Cross reference with F559.

Based on observation, clinical record review, interview, and document review, the facility failed to ensure that 38 of 38 residents (Resident #46, #270, #72, #83, #55, #421, #75, #277, #85, #54, #68, #61, #10, #222, #69, #4, #78, #20, #171, #1, #32, #38, #223, #48, #16, #35, #27, #19, #74, #96, #93, #34, #7, #2, #15, #9, #25, and #91) reviewed for immunizations were appropriately screened for eligibility to receive influenza (flu) and pneumococcal vaccines (PNA). The facility did not consistently determine the correct vaccine for each resident, provide education regarding the specific vaccines for which residents were eligible, or ensure that informed consent forms were properly completed and signed. Additionally, residents who were eligible to receive influenza or pneumococcal vaccines did not consistently receive the vaccinations as required. This deficient practice resulted in substandard quality of care and placed residents at increased risk for vaccine-preventable illnesses. Findings include: Resident #46 Resident #46 was admitted to the facility on [DATE], with diagnoses including chronic systolic (congestive) heart failure, and dependence on supplemental oxygen. Resident #270 Resident #270 was admitted to the facility on [DATE], with diagnoses including chronic systolic (congestive) heart failure, and chronic kidney disease, stage III. Resident #72 Resident #72 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, type II, with diabetic neuropathy, long term (current) use of insulin. Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, type II diabetes mellitus without complications, paroxysmal atrial fibrillation, and essential (primary) hypertension. Resident #55 Resident #55 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), unspecified asthma, uncomplicated, and severe sepsis with septic shock. Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pneumonia, unspecified organism, malignant neoplasm of esophagus, unspecified, protein-calorie malnutrition, and adult failure to thrive. Resident #75 Resident #75 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other specified complication, and unspecified protein-calorie malnutrition. Resident #277 Resident #277 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes mellitus without complications, and essential (primary) hypertension. Resident #85 Resident #85 was admitted to the facility o 04/29/2025, and readmitted on [DATE], with diagnoses including end stage renal disease, dependence on renal dialysis, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, peripheral vascular disease, unspecified, and type II diabetes mellitus without complications. Resident #54 Resident #54 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications, pulmonary hypertension, unspecified, acute respiratory failure with hypoxia, and dependence on supplemental oxygen. Resident #68 Resident #68 was admitted to the facility on [DATE], with diagnoses of malignant neoplasm of unspecified part of right bronchus or lung, and essential (primary) hypertension. Resident #61 Resident #61 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type I diabetes mellitus with ketoacidosis without coma, end stage renal disease, pulmonary hypertension, unspecified, anemia in chronic kidney disease, heart failure, unspecified, cardiomegaly, dependence on supplemental oxygen, and adult failure to thrive. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, adult failure to thrive, and essential (primary) hypertension. Resident #222 Resident #222 was admitted to the facility on [DATE], with diagnoses including unspecified asthma, uncomplicated, type II diabetes mellitus without complications, unspecified severe protein-calorie malnutrition, and essential (primary) hypertension. Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including chronic combined systolic (congestive) and diastolic (congestive) heart failure, and essential (primary) hypertension. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including paraplegia, unspecified, and direct infection of right hip in infectious and parasitic diseases. Resident #78 Resident #78 was admitted to the facility on [DATE], with diagnoses including COPD with (acute) exacerbation, emphysema, unspecified, pneumonia due to other gram-negative bacteria, and peripheral vascular disease, unspecified. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, unspecified, type II diabetes mellitus, chronic diastolic (congestive) heart failure, dependence on supplemental oxygen, and anemia in chronic kidney disease. Resident #171 Resident #171 was admitted to the facility on [DATE], with diagnoses including COPD unspecified, memory deficit following non-traumatic intracerebral hemorrhage, and seizures. Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, acute on chronic systolic (congestive) heart failure, pulmonary hypertension, unspecified, essential (primary) hypertension, and dependence on supplemental oxygen. Resident #32 Resident #32 was admitted to the facility on [DATE], with diagnoses including after care following joint replacement surgery, and essential (primary) hypertension. Resident #38 Resident #38 was admitted to the facility on [DATE], with diagnoses including COPD, unspecified, acute respiratory failure with hypoxia, unspecified protein-calorie malnutrition, chronic diastolic (congestive) heart failure, peripheral vascular disease, and malignant neoplasm of pharynx, unspecified. Resident #223 Resident #223 was admitted to the facility on [DATE], with diagnoses including acute on chronic diastolic (congestive) heart failure, other pulmonary embolism with acute cor pulmonale, and other pancytopenia. Resident #48 Resident #48 was admitted to the facility on [DATE], with diagnoses including acute transverse myelitis in demyelinating disease of central nervous system, and essential (primary) hypertension. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic kidney disease, stage III, unspecified, and essential (primary) hypertension. Resident #35 Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other sequelae of cerebral infarction, type II diabetes mellitus with hyperglycemia, chronic kidney disease stage III, unspecified, and essential (primary) hypertension. Resident #27 Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy, malignant neoplasm of brain, unspecified, paraplegia, incomplete, and acute respiratory failure with hypoxia. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including other seizures, occlusion and stenosis of right carotid artery, primary osteoarthritis, unspecified hand, and essential (primary) hypertension. Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, essential (primary) hypertension, and cognitive social or emotional deficit following cerebral infarction. Resident #96 Resident #96 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified atrial fibrillation, interstitial pulmonary disease, unspecified, primary pulmonary hypertension, right heart failure, unspecified, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, and dependence on supplemental oxygen. Resident #93 Resident #93 was admitted to the facility on [DATE], with diagnoses including end stage renal disease, unspecified asthma, uncomplicated, type II diabetes mellitus without complications, and dependence on renal dialysis. Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to embolism of left meddle cerebral artery, and essential (primary) hypertension. Resident #7 Resident #7 was admitted to the facility on [DATE], multiple sclerosis, and unspecified atrial fibrillation. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus, long term (current) use of insulin, end stage renal disease, and dependence on dialysis. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of right renal pelvis, traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness status unknown, subsequent encounter, pneumonia, unspecified organism, and acquired absence of kidney. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including pneumonia due to other gram-negative bacteria, acute respiratory failure with hypoxia, acute kidney failure, unspecified, and myocardial infarction type II. Resident #25 Resident #25 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia, pneumonia, unspecified organism, unspecified atrial fibrillation, acute kidney failure, unspecified, and dependence on supplemental oxygen. Resident #91 Resident #91 was admitted to the facility on [DATE], with diagnoses including neutropenia, unspecified, acute kidney failure, unspecified, and bacteremia. Influenza Vaccine A form titled Informed Consent for Influenza Vaccine: Inactivated/recombinant (Influenza Consent Form) last revised 09/2022, documented the following: -The facility must provide the most current edition of the Centers for Disease Control and Prevention (CDC) Vaccine Information Statement (VIS) for the vaccine to be administered. -The VIS form explained the risk and benefits of receiving the vaccine. -Residents/resident representatives should read the VIS before consenting to receiving the vaccine. -A section to enter the vaccine the resident was being offered and the date. -A section to document the date of the VIS form and the date the form was actually provided. -A check box indicating the resident/resident representative consented to having the vaccine administered and included acknowledgment education regarding the indicated vaccine had been provided and the resident/resident representative understood the risk and benefits of receiving the vaccine. -A check box indicating the resident did not consent to receiving the vaccine and included an acknowledgement the resident/resident representative, received education regarding the risk and benefits of the above vaccine. -The Influenza consent form did not including resident screening questions for eligibility including fever or other signs or symptoms of illness, allergies to medications, food, and/or vaccine components, a history of serious reaction to vaccines, health history, medications, history of administration of blood products, vaccination history, history of dizziness or fainting related to the administration of a vaccine, and how the resident felt about receiving the vaccine. An Influenza Consent Form signed by (Resident #270, #72, #83, #55, #75, #277, #85, #222, #4, #20, #1, #32, #223, #16, #27, #74, #93, #2, #9, and #25, or the residents' representative) documented the residents declined immunization with a flu vaccine. The Influenza Consent Forms did not include documentation of the type of flu vaccine offered and lacked documented evidence the residents were screened for eligibility to receive a flu vaccine, which flu vaccine was offered, and if education regarding the flu vaccine including the VIS form was provided. Resident #46, #61, #10, #35, #19, and #15 Resident #46, #61, #10, #35, #19, and #15, and/or the residents' representative, signed and/or verbally consented to the resident receiving a flu vaccine. The consent was documented on a blank/incomplete Influenza Consent Form and dated 10/02/2024. The Influenza Consent Form documented the residents had not been screened for eligibility to receive a flu vaccine, which flu vaccine to administer, and safety related to administration of the vaccine including history of allergies or reactions to a vaccine or contraindications related to the residents' health history, and if education related to the flu vaccine, including the VIS form, was provided. The residents' Immunization Reports documented the residents were/were not administered a flu vaccine as follows: -Resident #46, #61, #10, #19 and #15's Immunization Report documented the residents were administered Flucelvax influenza vaccine on 10/06/2024. -Resident #35's Immunization Report lacked documented evidence the resident was administered an influenza vaccine during the 2024/2025 flu season. Resident #96, #69, #48, 54, #171, and #68 A form titled Universal Vaccine Informed Consent/Declination Form, (Universal Consent), with an issue date of 07/25/2023. The Universal Consent form included a section to document the name of the vaccine being consented or declined, an acknowledgement of having read/received the VIS form for the vaccine named on the form, consent and declination boxes, and a vaccine administration grid. The Universal Consent form also contained a screening tool including questions regarding current health status, history of allergic reactions including foods, medications, and latex, post vaccination reactions, history of Guillain Barre Syndrome, and immunocompromising medications and diagnoses. The reason for declination was required to be documented on the form. If the vaccine was received elsewhere, the date and location were required to be documented. The Universal Consent form also included a grid for documenting the administration of a vaccine. Resident #96, #69, #54, #171, and #68's clinical record did not include an influenza consent form. Resident #96, #69, and #54's clinical record included a Universal Form completed as follows: -Resident #96's Universal Consent form, signed and dated 05/28/2025, the form was marked I do not give consent to being vaccinated with this vaccine because, however did not include the name or type of vaccine and did not include any additional documentation. -Resident #69's Universal Consent form, signed and undated, was marked I do not give consent to being vaccinated with this vaccine because but did not include the name or type of vaccine and did not include any additional documentation. A signature was entered into the line provided to document the reason the vaccine was being declined. The form did not include any additional documentation. -Resident #48's Universal Consent form, signed and dated 06/08/2025, was marked I do not give consent to being vaccinated with this vaccine because. The screening section was completed by drawing a line through the boxes labeled for each question on the form. The Universal Consent form did not include any additional documentation, including the name and type of vaccine. -Resident #54's Universal Consent form, signed and dated 06/07/2025, was marked I do not give consent to being vaccinated with this vaccine because, but did not include the name or type of vaccine. The screening section was completed by writing an X in the top box labeled No and a line was drawn through each of the remaining screening boxes. The Universal Consent form did not include any additional documentation, including the name and type of vaccine. -Resident #171's Universal Consent form, signed and dated 06/12/2025, was marked I give consent but did not include any additional information including the name and/or type of vaccine. -Resident #68's Universal Consent form, signed and dated 05/28/2025, was marked I give consent and the screening section was completed by placing a mark in the no box for each question. The form did not include any additional information including the name and/or type of vaccine. Resident #38, #421, #7, #91, and #34 Resident #38, #421, #7, #91, and #34's clinical record did not include an Influenza Consent form or a Universal Consent form, and did not include any additional documentation related to screening the residents for eligibility to receive a flu vaccine, the type of flu vaccine the resident was eligible to receive, if the resident consented or declined the vaccine and if education regarding the vaccine was provided to the residents. The Residents' immunization reports documented the following: -Resident #38 Immunization Record documented the resident was last administered a flu vaccine on 09/06/2023. -Resident #421 Immunization Record documented the resident was last administered a flu vaccine on 08/29/2024. The vaccination was documented as historical but did not document where the vaccine was received. -Resident #7 was last administered a flu vaccine on 10/10/2024. The vaccination was documented as historical but did not document where the vaccine was received. -Resident #91's Immunization Record documented the resident was not eligible to receive a flu vaccine and did not document the reason why. -Resident #34's Immunization Record documented the resident was last administered a flu vaccine on 03/02/2023. The vaccine was administered by the facility. Resident #38 Resident #38's Influenza Consent form documented a verbal consent was obtained on 11/19/2024. The form lacked any additional documentation, including if the resident's responsible party did or did not consent to the resident receiving a flu vaccine. The form did not document the resident was screened for eligibility, the type of flu vaccine and the education offered for the vaccine, including a VIS. The facility policy titled Influenza Vaccine Policy for Resident revised on 01/28/2025, documented consents and declinations were documented annually and entered into the residents' medical record. The facility re-addressed refusals with residents and/or the residents' representative each year to ensure the resident or the resident's representative had not changed their decision. These conversations were entered into the medical record. Education was provided the resident and/or the resident representative by providing the VIS form for the vaccine to be administered. The resident was assessed/screened for possible contraindications and if noted the physician was notified for further instructions. Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring were documented in the resident's medical record. Pneumococcal Vaccine Resident #421 and #91 Resident #421 and Resident #91's clinical record did not include documented evidence the residents were screened for eligibility to receive a PNA vaccine, education regarding PNA vaccines was provided, and consent was obtained to receive a PNA vaccine, or the vaccine was declined. Resident #421's Immunization Report did not include documentation of a PNA vaccine being administered or declined. Resident #91's Immunization Report documented the resident had refused immunization with a pneumococcal vaccine; the entry was undated. Resident #4, #1, #19, and #15 Resident #4, #1, #19, and #15's clinical records lacked documented evidence the residents were screened for eligibility to receive a PNA vaccine, provided education regarding the PNA vaccine the resident was eligible to receive, and either consented or did not consent to vaccination with a pneumococcal vaccine when CDC guidance was updated, and new vaccines became available. The residents were last screened for PNA vaccines as follows: -Resident #4 and #15's clinical record included a form titled Informed Consent for Pneumococcal Vaccine PCV13, (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide) signed and dated 10/21/2021, documented Resident #4 declined to receive vaccination with a pneumococcal vaccine. -Resident #4's Immunization Report documented the resident was administered a PNA vaccine on 12/23/2015. The Immunization Report documented the resident had refused a PNA vaccine twice, but did not document a date the vaccines were declined. -Resident #15's Immunization Report documented the resident was administered a PNA vaccine on 12/14/2023. The Immunization Report documented the resident had refused a PNA vaccine twice, but did not document a date the vaccines were declined. -Resident #1's clinical record included a form titled Informed Consent for Pneumococcal Vaccine. The form was undated, but documented parts of the form were excerpted from CDC VIS forms dated 11/05/2015 (PCV-13 vaccine) and 04/24/2015 (PPSV vaccine). -Resident #1's Immunization Record lacked documentation the resident had ever received immunization with a pneumococcal vaccine. -Resident #19's clinical record included a form titled Informed Consent for Pneumococcal Polysaccharide Vaccine (for PCV13 consent see CP1818). The form was undated, but documented parts of the form were excerpted from a CDC VIS form for Pneumococcal Polysaccharide Vaccine dated 01/06/2009. The form was signed and dated 02/26/2023, and documented a PNA vaccine was declined. -Resident #19's Immunization Record documented the resident had refused a pna vaccine twice, the refusals were not dated. The Immunization Record documented the resident was administered a dose of Pneumovax (PPSV23) on 09/06/2023. The facility was not able to provide updated documentation of screening, education, and/or a signed consent for vaccination with, or declination of a PNA vaccine per the most recent CDC guidance for Resident #4, #1, #19, and #15. Resident #46, #10, #78, #72, #16, #27, and #34 A form titled Informed Consent for Pneumococcal Vaccine PCV-15 or PCV-20 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide) (PNA Consent 1) dated 04/2022, included information regarding the three PNA vaccine recommended by the CDC as of 04/2022. The PNA Consent 1 form documented individuals over [AGE] years of age who had not previously received vaccination with PCV-15 or PCV-20 or had an unknown vaccination should be administered a dose of either PCV-15 or PCV-20. If PCV-15 was used, it should be followed with a dose of PPSV23 at least one year later. The PNA Consent 1 form documented the most current edition of the CDC's VIS must be provided to the resident and/or the resident's representative for the vaccine the individual was determined to be eligible to receive. The form encouraged the individual receiving the vaccine to read the VIS prior to consenting. The PNA Consent 1 form included a section for documenting which vaccine (PCV-15, PCV-20 and PPSV-23) was being offered and the date. The PNA consent form included a section to document which of the VIS forms was provided, the date of the VIS form, and the date the education was provided. The PNA Consent 1 form included a section to consent and a section to decline to consent. Both sections, I consent or I do not consent, documented the consenting party (resident and/or resident representative) received information about the risk and benefits of the vaccine being offered. Resident #46, #10, #78, #16, #27, and #34's PNA Consent 1 form included the resident and/or the resident representatives' signature, and I do not consent was selected for each of the residents. The PNA Consent 1 forms signed by the Resident #46, #10, #78, #72, #16, #27, and #34, and/or the residents representative, did not include screening for eligibility. The sections of the PNA 1 Consent form indicating the PNA vaccine offered and the date the vaccine was offered was not completed, and the section documenting which VIS form was provided, the date of the VIS form, and the date the VIS form (education) was provided to the resident and/or the residents' representative was left blank. The Immunization Records for Resident #46, #10, #78, #16, #27, and #34, documented PNA vaccines were received or refused as follows: -Resident #46, one dose of PPSV23 was given on 11/01/2021 (historical). Not eligible was documented twice and was undated. -Resident #10, documented PPSV23 was administered on 09/06/2023. A PNA vaccine was documented as refused one time. -Resident #78, lacked documentation related to a PNA vaccine. -Resident #16, a PNA vaccine was documented as refused one time, undated. -Resident #27, a PNA vaccine was documented as refused one time, undated. -Resident #34, one dose of PPSV23 was given on 10/30/2021. Not eligible was documented twice and was undated. Resident #72's PNA Consent 1 form included the resident's signature and was dated 09/11/2024. The form documented the resident consented to receive a PNA vaccine. The PNA Consent 1 forms signed by Resident #72 did not include screening for eligibility. The sections of the PNA 1 Consent form indicating the PNA vaccine offered and the date the vaccine was offered was not completed, and the section documenting which VIS form was provided, the date of the VIS form, and the date the VIS form (education) was provided to the resident was left blank. Resident #72's Immunization Record lacked documented evidence the resident was administered a PNA vaccine at any time. Per the CDC's PneumoRecs VaxAdvisor Residents #46, #10, #78, #72, #16, #27, and #34 were eligible to receive a PNA vaccine based on the residents age and/or qualifying comorbidities, such as end stage renal failure and dependence on dialysis. The facility was not able to provide updated documentation of screening, education, and/or a signed consent for vaccination with, or declination of a PNA vaccine per the most recent CDC guidance for Resident #46, #10, #78, #72, #16, #27, and #34. Resident #55, #75, #20, #61, and #35 A form titled Informed Consent for Pneumococcal Vaccine PCV-15, PCV-20, or PCV-21 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide) (PNA Consent 2) form dated 09/2024, included information regarding PNA vaccination recommendations for vaccination. The PNA Consent 2 form documented individuals over [AGE] years of age who had not previously received a Pneumococcal Conjugate vaccine, or had an unknown vaccination history, should be administered a dose of either PCV-15, PCV-20, or PCV21. If PCV-15 was used, it should be followed with a dose of PPSV23 at least one year later. The form documented the most current edition of the CDC's VIS must be provided for the vaccine the individual was determined to be eligible to receive. The form encouraged the individual receiving the vaccine to read the VIS prior to consenting. The PNA Consent 2 form included a section for documenting which vaccine (PCV-15, PCV-20, PCV-21 and PPSV-23) was being offered and the date. The PNA consent form included a section to document which of the VIS forms was provided, the date on the VIS form, and the date the education was provided. The PNA Consent 2 form included a section to consent and a section to decline to consent. Both sections, I consent or I do not consent, documented the consenting party (resident and/or resident representative) received information about the risk and benefits of the vaccine being offered. Resident #55, #75, #20, #61, and #35 PNA Consent 2 form included the resident and/or the resident representatives' signature, and I do not consent was selected for each of the residents. The PNA Consent 2 forms signed by Resident #55, #75, #20, #61, and #35, and/or the residents' representative, did not include screening for eligibility. The sections of the PNA Consent 2 form indicating the PNA vaccine offered and the date the vaccine was offered was not completed, and the section documenting which VIS form was provided, the date of the VIS form, and the date the VIS form (education) was provided to the resident and/or the residents' representative was left blank. The Immunization Records for Resident #55, #75, #20, #61, and #35 documented PNA vaccines were received or refused as follows: -Resident #55, Pneumovax was refused one time, undated. -Resident #75, a dose of PPSV23 was refused one time, undated. One dose of PCV20 was administered on 10/07/2024 (historical). -Resident #20, a dose of PPSV23 was refused two times, undated. One dose of PCV20 was administered on 02/15/2023 (historical). -Resident #61, no documentation a PNA vaccine was refused or administered. -Resident #35, a dose of PPSV23 was refused one time. Per the CDC's PneumoRecs VaxAdvisor Per the CDC's PneumoRecs VaxAdvisor Residents #55, #75, #20, #61, and #35 were eligible to receive a PNA vaccine based on the residents age and/or qualifying comorbidities, such as end stage renal failure and dependence on dialysis. The facility was not able to provide updated documentation of screening, education, and/or a signed consent for vaccination with, or declination of a PNA vaccine per the most recent CDC guidance for Resident #55, #75, #20, #61, and #35 Resident #270, #83, #277, #85, #54, #69, #222, #69, #171, #32, #38, #48, #223, #74, #96, #93, #7, #2, #9, and #25. A form titled Informed Consent for Pneumococcal Vaccine PCV-15, PCV-20, or PCV-21 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide) (PNA Consent 3) form dated 01/2025, included information regarding PNA vaccine recommendations. The PNA Consent 3 form contained the most recent CDC guidance for immunization with flu vaccines. The PNA Consent 3 form documented individuals over [AGE] years of age and those at increased risk for pneumococcal disease, who had not previously received a Pneumococcal Conjugate vaccine, or had an unknown vaccination history, should be administered a dose of either PCV-15, PCV-20, or PCV21. If PCV-15 was used, it should be followed with a dose of PPSV23 at least one year later. The PNA Consent 3 form documented the most current edition of the CDC's VIS must be provided for the vaccine the individual was determined to be eligible to receive. The form encouraged the individual receiving the vaccine to read the VIS prior to consenting. The PNA Consent 3 form included a section for documenting which vaccine (PCV-15, PCV-20, PCV-21 and PPSV-23) was being offered and the date. The PNA consent form included a section to doc

Based on interview, clinical record review, and document review, the facility failed to ensure consents for psychotropic medications were obtained for 1 of 24 sampled Residents (Resident #421). The deficient practice had the potential to deprive a resident/resident representative of the right to be informed of the medications' purpose, risks, benefits, and potential side effects. Findings include: Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, depression, anxiety disorder unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order dated 06/19/2025, documented Sertraline HCl oral tablet 100 milligram (mg). Give one tablet enterally two times a day for depression, as evidenced by, sad facial expression. A physician's order dated 06/19/2025, documented Quetiapine Fumarate oral tablet 50 mg. Give one tablet enterally at bedtime for bipolar disorder, as evidenced by, mood swings. A physician's order dated 06/19/2025 documented Buspirone HCl oral tablet 10 mg. Give two tablets enterally two times a day for anxiety, as evidenced by, verbalization of anxiety, 20 mg total. Resident #421's care plan initiated on 06/22/2025, documented the resident used antidepressant medication (Sertraline HCl oral tablet) related to depression, as evidenced by, sad facial expression. Resident #421's care plan initiated on 06/22/2025, documented the resident used antipsychotic medications (Quetiapine Fumarate oral tablet) related to behavior management/mood swings. Resident #421's care plan initiated on 06/24/2025, documented the resident used anti-anxiety medications. Resident #421's clinical record lacked psychotropic consent forms indicating the resident accepted to take the medication and was explained risks and benefits associated with the psychotropic medications. On 06/26/2025 at 11:30 AM, the Director of Nursing (DON) explained a psychotropic medication consent gave permission from the resident to administer a psychotropic medication to the resident and provided information to the resident of risks and benefits and side effects associated with the psychotropic medications. The DON confirmed Resident #421 received antipsychotic medications daily and did not have a psychotropic consent completed for the use of Sertraline, Quetiapine, and Buspirone. The facility policy titled Psychotropic Medication Informed Consent Policy, last revised 04/22/2025, documented the facility would obtain consent or refused for the use of a psychotropic medication. The consent would document the intended actual benefit of the medication, and justify the potential risks of the medication, and would indicate understanding from the resident and/or resident representative of those risks and benefits. The facility policy titled Resident Rights, last revised 09/10/2024, documented the resident had the right to be informed in advance of the risks and benefits of proposed care.

Based on clinical record review, interview, and document review, the facility failed to ensure a Minimum Data Set 3.0 (MDS) assessment was accurate for 3 of 24 sampled residents (Resident #421, #2 and #171). This deficient practice had the potential to deprive residents of necessary care and services relative to current health management needs in the facility. Findings include: Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, depression, anxiety disorder unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order dated 06/19/2025, documented Quetiapine Fumarate oral tablet 50 mg. Give one tablet enterally at bedtime for bipolar disorder, as evidenced by, mood swings. A physician's order dated 06/19/2025, documented Sertraline HCl oral tablet 100 milligram (mg). Give one tablet enterally two times a day for depression, as evidenced by, sad facial expression. Resident #421's Medication Administration Record (MAR) for June 2025 documented Quetiapine Fumarate 50 mg tablet was administered to the resident from 06/19/2025 to current. Resident #421's MAR for June 2025 documented Sertraline HCl 100 mg tablet was administered to the resident from 06/19/2025 to current. An MDS assessment dated [DATE], Section I - Active Diagnoses, Psychiatric/Mood Disorder lacked an X or any other documentation the resident had diagnoses of bipolar disorder and depression. On 06/26/2025 at 11:30 AM, the Director of Nursing (DON) explained the resident had diagnoses to include bipolar disorder and depression and was being administered antipsychotic medications used to treat the diagnoses. The DON verbalized those diagnoses should be documented on the MDS to accurately identify care concerns for the resident. The DON confirmed the diagnoses of bipolar and depression were not documented on the resident's MDS. On 06/26/2025 at 9:45 AM, the MDS Coordinator explained the resident diagnoses were input on the resident MDS assessments and needed to be accurate. Bipolar disorder and depression needed to be input on the residents' MDS if a resident had those diagnoses. The MDS Coordinator confirmed Resident #421 had diagnoses of bipolar disorder and depression and the assessment was inaccurate. Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, dependence on renal dialysis, muscle weakness, and difficulty walking. An Event Note dated 05/07/2025, documented the resident had fallen while attempting to self-transfer. A Transfer to Hospital Summary dated 05/07/2025, documented Resident #2 was to be transferred and admitted to the hospital due to a fracture of the right hip. Resident #2's Minimum Data Set (MDS) 3.0 dated 05/07/2025, Discharge Return Anticipated, Section J-Health Conditions, J1800 documented: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? No. On 06/26/2025 at 11:05 AM, the MDS Coordinator, Registered Nurse (RN) confirmed Resident #2's MDS dated [DATE] was not coded correctly and did not reflect the resident's fall with injury. The MDS Coordinator RN confirmed Section J1800 should have been coded as yes since the fall with injury was the reason for the transfer to the hospital. On 06/26/2025 at 11:08 AM, the MDS Coordinator RN verbalized having followed the MDS 3.0 Resident Assessment Instrument (RAI) Manual to complete resident assessments. Resident #171 Resident #171 was admitted to the facility on [DATE], with a primary diagnosis of unspecified nondisplaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing. A physician's order dated 06/13/2025, documented Hydroxyzine Hydrochloride (HCl) 10 mg tablet. Give one tablet by mouth two times a day for anxiety as exhibited by verbalization of anxiety for 14 days. Resident #171's June 2025 MAR documented Hydroxyzine HCl was administered the night of 06/13/2025, twice daily from 06/14/2025 through 06/26/2025, and the morning of 06/27/2025. Resident #171's Admissions MDS assessment dated [DATE], section N0415 (Medications - High-Risk Drug Classes: Use and Indication) lacked an X or any other documentation an antianxiety medication was administered to the resident during the seven-day lookback period. On 06/30/2025 at 11:09 AM, a RN confirmed Resident #171's clinical record documented an order of Hydroxyzine HCl with an indication of anxiety. On 06/30/2025 at 12:02 PM, the MDS Coordinator verbalized using the RAI Manual to guide MDS activities. It was important MDS Assessments be accurate to accurately convey resident needs. The MDS Coordinator confirmed Resident #171 received Hydroxyzine HCl from 06/13/2025 through 06/27/2025. Hydroxyzine HCl was classified as an antianxiety medication and should have been reflected on the MDS Assessment.

Based on observation, interview, record review and document review, the facility failed to ensure an initial Preadmission Screening and Resident Review (PASARR) was completed prior to a resident's admission for 1 of 24 sampled residents (Resident #421). The deficient practice had a potential for a newly admitted resident not to receive the necessary screening for the appropriateness to be admitted to a skilled nursing facility. Findings include: Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, depression, anxiety disorder unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 06/25/2025, during review of Resident #421's clinical record, a PASSAR Level 1 could not be located. Resident #421's Care Plan, initiated on 06/22/2025, documented the resident was on psychotropic medications related to behavior management, mood swings, depression, and anxiety. On 06/25/2025 at 3:41 PM, the Regional Director of Clinical Services provided a PASSAR Level 1 submission submitted on 04/09/2008, however verbalized a PASSAR Level 1 could not be located for the resident. The Regional Director of Clinical Services verbalized being unaware if the resident was receiving psychiatric services. On 06/25/2025 at 4:39 PM, the Regional Director of Clinical Services confirmed the facility did not have a PASSAR Level 1 completed for Resident #421 to determine if the resident was appropriate for Skilled Nursing Facility placement. The Regional Director of Clinical Services explained residents could not admit to a facility without a PASSAR Level 1. On 06/25/2025 at 4:40 PM, the Director of Nursing (DON) explained Resident #421 did not require a PASSAR Level 1 in order to be admitted to a Skilled Nursing Facility based off of the resident's diagnoses and could not explain why the purpose of a PASSAR Level 1 would be important for a resident. On 06/26/2025 at 9:04 AM, the Business Office Manager (BOM) explained when residents were admitted to the facility, a PASSAR Level 1 was required to be obtained to determine proper placement and services a resident may need. The BOM confirmed the facility did not have a PASSAR Level 1 for Resident #421 and a PASSAR Level 1 submission from 2008 would be inappropriate to use because the admitting diagnoses of a resident could be different from diagnoses in 2008. On 06/26/2025 at 9:39 AM, the Director of Clinical Services explained the facility reviewed the last two years of diagnoses for a resident. If the resident did not have mental illness diagnoses prior to the last two years but had mental illness diagnoses now, the facility needed to submit for a PASARR Level 1 to cover all care areas for the resident. The facility policy titled Pre-admission Screening and Resident Review (PASARR), last reviewed 09/26/2024, documented a PASSAR Level 1 screening was to be completed for residents prior to admission to the facility and a record would be retained in the resident's medical record.

Based on clinical record review, document review, and interview, the facility failed to ensure a baseline care plan was developed to address the care and interventions for mental health diagnoses for 1 of 24 sampled residents (Resident #421) and to ensure the proper care and services for a resident with a Foley catheter for 1 of 24 sampled residents (Resident #69). The deficient practice had the potential to deprive a resident of proper care and services related to mental health conditions and the potential to place the resident at risk for not receiving appropriate care related to a Foley catheter. Findings include: Resident #421 Resident #421 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including bipolar disorder, depression, anxiety disorder unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #421's physician's orders documented: -Quetiapine Fumarate oral tablet 50 milligram (mg). Give one tablet enterally at bedtime for bipolar disorder, as evidenced by mood swings. The physician's order was dated 06/19/2025. -Buspirone HCl oral tablet 10 mg. Give two tablets enterally two times a day for anxiety, as evidenced by verbalization of anxiety, 20 mg total. The physician's order was dated 06/19/2025. Resident #421's baseline care plan dated 06/19/2025, lacked a care plan for the care, treatment, and interventions for bipolar disorder and anxiety. On 06/26/2025 at 11:30 AM, the Director of Nursing (DON) reviewed Resident #421's baseline care plan and confirmed the diagnoses of bipolar disorder and anxiety were not included on the resident's care plan. The DON explained a care plan for the diagnoses would be beneficial for the facility to understand the care needs of the resident and how to properly care for the resident. Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including retention of urine, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. A physician's order dated 06/09/2025, documented indwelling catheter to straight drainage. Size : 16 French Bulb; 10 milliliter (ml). Change for clogging or dislodgement as needed for benign prostatic hyperplasia for infection, obstruction or when the closed system is compromised. The admission Minimum Data Set (MDS) 3.0 dated 06/12/2025, Section H-Bladder and Bowel, documented the resident had an indwelling catheter. A baseline care plan dated 06/10/2025, documented the resident had (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter. The interventions included: -catheter care every shift; -educate resident and/or family regarding indwelling catheter and care; -enhanced barrier precautions. On 06/25/2025, the Director of Nursing (DON) explained Resident #69 had a Foley catheter and confirmed the resident's care plan did not specify what type of catheter the resident had nor proper interventions for care related to the catheter. The interventions the DON expected to see on a Foley catheter care plan would be type of care for the catheter, goals and expectations for the catheter, the type and size of the catheter, observing for pain/discomfort, and checking the Foley catheter for placement. The DON verbalized the information would be important to include on the resident's care plan for staff to refer for care needs for the resident. On 06/25/2025 at 1:09 PM, the Regional Director of Clinical Services confirmed the care plan was not completed for Resident #69 and explained the Foley catheter was critical to care plan for the care of this resident. The Regional Director of Clinical Services verbalized a care plan should never document the word specify in place of the specific care area. The facility policy titled Baseline Care Plan, last reviewed 09/05/2024, documented a baseline care plan would be developed within 48 hours of a resident admission to the facility and the care plan would be updated to reflect current care needs of the resident. The facility policy titled Indwelling urinary catheter (Foley) care and management', undated, documented monitoring of the catheter daily and assess for complications resulting from the use of an indwelling catheter, such as, symptoms of blockage associated with bypassing of urine, catheter associated urinary tract infection (CAUTI), expulsion of the catheter, pain, discomfort, and bleeding. An individual care plan based on the information would be developed and revised as necessary.

Based on interview, clinical record review, and document review, the facility failed to develop a person-centered Comprehensive Care Plan for the needed care and services related to 1) a Foley catheter for 1 of 24 sampled residents (Resident #69), 2) bowel and bladder retraining for 2 of 24 sampled resident (Resident #9 and #54), and 3) pain management for 1 of 24 sampled residents (Resident #223). This deficient practice had the potential to delay adequate care and interventions to properly manage concerns related to Foley catheter care, bowel and bladder retraining, and pain management. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including retention of urine, unspecified, benign prostatic hyperplasia without lower urinary tract symptoms, and chronic combined systolic (congestive) and diastolic (congestive) heart failure. A physician's order dated 06/09/2025, documented indwelling catheter to straight drainage. Size : 16 French Bulb; 10 milliliter (ml). Change for clogging or dislodgement as needed for benign prostatic hyperplasia for infection, obstruction or when the closed system is compromised. The admission Minimum Data Set (MDS) 3.0 dated 06/12/2025, Section H-Bladder and Bowel, documented the resident had an indwelling catheter. A care plan dated 06/10/2025, documented the resident had (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter:. The interventions included: -catheter care every shift; -educate resident and/or family regarding indwelling catheter and care; -enhanced barrier precautions. On 06/25/2025 at 8:48 AM, the Director of Nursing (DON) explained Resident #69 had a Foley catheter and confirmed the resident's care plan was not revised and did not specify what type of catheter the resident had nor proper interventions for care related to the catheter. The interventions the DON expected to see on a Foley catheter care plan would be type of care for the catheter, foals and expectations for the catheter, the type and size of the catheter, observing for pain/discomfort, and checking the Foley catheter for placement. The DON verbalized the information would be important to include on the resident's care plan for staff to refer for care needs for the resident. On 06/25/2025 at 1:09 PM, the Regional Director of Clinical Services confirmed the care plan was not completed and not revised for Resident #69 and explained the Foley catheter was critical to care plan for the care of this resident. The Regional Director of Clinical Services verbalized a care plan should never document the word specify in place of the specific care area. The facility policy titled Indwelling urinary catheter (Foley) care and management, undated, documented monitoring of the catheter daily and assess for complications resulting from the use of an indwelling catheter, such as, symptoms of blockage associated with bypassing of urine, catheter associated urinary tract infection (CAUTI), expulsion of the catheter, pain, discomfort, and bleeding. An individual care plan based on the information would be developed and revised as necessary. Resident #9 Resident #9 was admitted to the facility on [DATE], with a principal diagnosis of pneumonia due to other gram-negative bacteria. Resident #9's Minimum Data Set 3.0 (MDS) assessment dated [DATE], section H (Bladder and Bowel) documented the following: -A trial of a toileting program had not been attempted. -The resident was always incontinent of bladder. -The resident was always incontinent of bowel. -A toileting program was not being used to manage the resident's bowel incontinence. A care plan dated 05/21/2025, documented the resident had urinary incontinence. The care plan did not include individualized, measurable objectives or specific interventions for bowel and bladder management, nor did it reflect the resident's goals or preferences. The interventions included: -assist with toileting as needed -offer toilet before meals and at bed time; -peri care as needed. On 06/26/2025 at 2:13 PM, the DON explained the bowel and bladder evaluation was completed upon admission to determine the resident's continence status. Once the resident's continence status was determined the evaluation was completed and the score would determine the interventions appropriate for the resident. The DON confirmed Resident #9 was a candidate for toileting, timed or scheduled voiding, and lacked person centered interventions and was unable to determine if the intervention of rounding every two hours was appropriate or an effective intervention for Resident #9. The facility policy titled Comprehensive Care Plans and Revisions, last reviewed 09/11/2024, documented the facility should monitor the resident to help identify changes in a resident's condition that may warrant an update to the person-centered plan of care. The plan of care would document interventions on existing problems, updating goals or problem statements, and adding short term problems, goals, and interventions to address a condition. Resident #54 Resident #54 was admitted to the facility on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the digestive system and acute (reversible) ischemia of small intestine, extent unspecified. Resident #54's MDS assessment dated [DATE], section H (Bladder and Bowel) documented the following: -A trial of a urinary toileting program had not been attempted. -The resident was frequently incontinent of urine. -The resident was frequently incontinent of bowel. -A toileting program was not being used to manage the resident's bowel incontinence. An Evaluation for Bowel and Bladder Training dated 06/07/2025, documented Resident #54 was a candidate for toileting, timed or scheduled voiding. Resident #54's Care Plan included the following: -Focus: Bowel Incontinence. Goal: Resident would have no skin breakdown related to bowel incontinence. Interventions included assist with toileting as needed and pericare as needed. The date initiated was 06/08/2025. -Focus: Urinary Incontinence. Goal: Resident would have no skin breakdown related to urinary incontinence. Interventions included assist with toileting as needed and pericare as needed. The date initiated was 06/08/2025. On 06/26/2025 at 2:13 PM, the DON explained a resident's continence status was assessed upon admission using a bowel and bladder assessment in the facility's electronic medical record (EMR) system. After the assessment was complete, interventions to help manage incontinence would be added to the resident's care plan. The DON confirmed Resident #54's Evaluation for Bowel and Bladder Training documented the resident was a candidate for toileting, timed or scheduled voiding and the resident's Care Plan lacked resident-specific interventions to maintain continence and/or restore as much normal bowel and bladder function as possible. Resident #223 Resident #223 was admitted to the facility on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the circulatory system and chronic pain syndrome. On 06/24/2025 at 9:05 AM, Resident #223 verbalized the resident had chronic pain and regularly took pain medication at home to manage the pain. The resident reported having current abdominal and back pain, the pain was rated ten on a 0-10 scale, and the pain prevented the resident from walking. Resident #223's MDS assessment dated [DATE], Section J (Health Conditions) documented the following within the previous five days: -The resident had received As Needed (PRN) pain medications or PRN pain medications had been offered and declined. -The resident had not received a non-medication intervention for pain. -The resident had pain or hurting. -The pain rarely made hard for the resident to sleep. -The pain occasionally limited participation in rehabilitation therapy sessions and limited day-to-day activities. Resident #223's Care Plan documented the following focuses, goals and interventions: -Focus: Resident at risk for rehospitalization due to congestive heart failure, atrial fibrillation, pulmonary embolism, obesity, and chronic pain. Interventions included: Provide medications as ordered, interdisciplinary team to meet as needed to discuss resident's condition and interventions. The date initiated was 06/20/2025. -Focus: Resident is on pain medication therapy related to congestive heart failure, pulmonary embolism, and bilateral lower extremity edema. Goal: The resident would be free of any discomfort or adverse side effects from pain medication. Interventions included: Administer analgesic medications as ordered by physician. Observe for side effects and effectiveness every shift. The date initiated was 06/22/2025. -Focus: Resident expresses pain/discomfort related to chronic pain disorder. Goal: The resident will express pain relief. Interventions included: Educate resident regarding pain management, evaluate effectiveness of pain interventions, pain medications as ordered. The date initiated was 06/20/2025 and the revised date was 06/22/2025. Resident #223's Order Summary Report included the following physician orders: -PainAD Assessment: Location of pain: 1) generalized, 2) back, 3) leg, 4) head. Attempt non-med interventions prior to administering PRN pain medications: 1) calm/quiet environment, 2) reposition, 3) redirection, 4) elevate extremities. Every shift, do not arouse from sleep. Do not exceed 3,000 milligrams (mg) Acetaminophen in a 24 hours period from all sources. Document pain level, location of pain, and intervention used. -Acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for pain scale 1-3. -Oxycodone Hydrochloride (HCl) oral tablet 5 mg, give one tablet by mouth every four hours as needed for pain scale 4-6. -Oxycodone HCl oral tablet 5 mg, give two tablets by mouth every four hours as needed for pain scale 7-10. On 06/30/2025 at 9:59 AM, the DON verbalized the facility ensured both non-pharmacological and pharmacological interventions were used to manage residents' pain by asking the resident about which non-pharmacological interventions the resident had used in the past. Staff were to attempt non-pharmacological interventions for pain prior to administering medication. The DON confirmed all interventions being used to manage a resident's pain should be included on the resident's Care Plan. The DON confirmed Resident #223 had pain and verbalized interventions for pain management for the resident included Oxycodone, Tylenol, elevation of extremities, calm and quite environment, repositioning and redirection. The DON confirmed the non-pharmacological interventions were not on the resident's care plan. The facility policy titled Area of Focus: Care Planning - Baseline, Comprehensive, and Routine Updates, reviewed 11/25/2024, documented a comprehensive care plan was to be completed to address the resident's goals and preferences, contain measurable objectives and timeframes, and interventions to assist the resident to meet their goals. Selecting interventions and planning care included identifying and implementing interventions and treatments to address the individual's physical, functional, and psychosocial needs, concerns, problems and risks. Cross reference tag F690 and F697

Based on personnel record review, document review and interview, the facility failed to ensure an employee had current cardiopulmonary resuscitation (CPR) training. This deficient practice placed residents at risk from an employee not having completed all employment eligibility requirements. Findings include: Employee #9 Employee #9 had a hire date of [DATE] and a title of Certified Nursing Assistant. Employee #9's personnel record documented a CPR certification with an expiration date of [DATE]. On [DATE] at 8:39 AM, the Staff Development Coordinator, Registered Nurse (RN), verbalized having been responsible to ensure all staff received the required certifications and confirmed Employee #9's CPR certification had expired on [DATE]. The Staff Development Coordinator RN verbalized not having been sure if Employee #9 had current CPR training. Employee #9's job description, signed by Employee #9 on [DATE], documented the employee must have obtained CPR certification and the certification must remain current during employment. The facility policy titled, Cardiopulmonary Resuscitation (CPR) Policy, revised [DATE], documented employees must maintain current CPR certification for those employees providing care to residents.

Based on observation, clinical record review, interview, and document review, the facility failed to ensure communication was maintained between the facility and the hospice agency providing care to 1 of 1 hospice residents residing in the facility (Resident #27) This deficient practice had the potential to result in the facility not being updated regarding the care the resident was receiving from the hospice agency, changes in the resident's condition, changes to frequency of care, new physician orders, and instructions for new physician orders. Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, paraplegia incomplete, and malignant neoplasm of the brain. A physician's order dated 02/22/2025, documented to admit Resident #27 to Hospice for a diagnosis of glioblastoma of the brain (a malignant neoplasm). Resident #27's Hospice Care Binder was located at the nurses' station. The Binder included a nurse visit progress note dated 02/21/2025, and did not include any additional progress notes from the hospice. On 06/30/25 at 10:26 AM, a Registered Nurse (RN) verbalized a resident's hospice binder was important because the binder was reviewed by facility nurses. The Hospice Nurse Notes were reviewed to determine if there was anything new regarding the resident or the resident's care the facility nurse should have been aware of. The RN confirmed the Hospice Nurse Notes should be located in the resident's Hospice Binder under nurse progress notes, and confirmed the notes were not present as expected in Resident #27's Hospice Binder. On 06/30/25 at 11:23 AM , the Director of Nursing (DON) verbalized the DON's expectation was a Nurse's note for each hospice visit would be in the resident's hospice binder. The DON verbalized all the notes from the hospice nurse visits were to be placed into the same section of the Hospice Binder. The DON explained nursing staff used the hospice nurse notes as a reference for care of the resident and included the resident's status. On 06/30/25 at 11:26 AM, the DON explained the facilities Interdisciplinary Team (IDT) reviewed hospice patient care every Wednesday Morning, including the nurse progress notes located in the Hospice Binder. The progress notes were used to help the IDT understand/know the care the resident was receiving and guide discussion related to the resident's care. The DON confirmed Hospice Binders were reviewed weekly in IDT meetings and confirmed the absence of the Hospice Nurse progress notes should have been identified and this time. On 06/30/25 at 11:33 AM, the DON reviewed Resident #27's Hospice Binder and confirmed the Hospice Nurse Progress Note dated 02/22/2025, was the only nurse progress note in Resident #27's Hospice Binder. The DON confirmed there should have been one note per week in the resident's hospice binder based on the hospice nurse's visit frequency of one visit per week. One visit per week, including the first visit conducted on 02/22/2025 equaled approximately 17 visits. The DON verbalized the concern with the lack of communication between the hospice agency and the facility was the facility would not know what care was provided the and what the hospice's plan was for upcoming care. The facility policy titled Area of Focus: Hospice reviewed 11/19/2024, documented the IDT ensured communication between the facility and hospice.