Every finding on record at Marquis Mill Park

Based on observation, interview and record review it was determined the facility failed to administer the correct medications for 1 of 3 sampled residents (#45) reviewed for hospitalizations. This failure resulted in Resident 45 experiencing decreased blood pressure and hospitalization. Findings include: The facility's Administering Medications policy revised 12/2025 included the following:- Medications shall be administered in a safe and timely manner, and as prescribed.- Medications must be administered in accordance with the orders.- The individual administering medications must verify the resident's identity before giving the resident her/his medications.- The individual administering the medication must check the label three times to verify the right medication, right dosage, right time and right method of administration before giving the medication.Resident 45 was admitted to facility in 4/2026 with diagnoses including encounter for surgical aftercare following surgery on the digestive system and essential hypertension (high blood pressure).The Admissions MDS with an ARD of 4/23/26 revealed Resident 45 had a BIMS score of 14, which indicated the resident was cognitively intact. A review of Resident 45's medication administration record revealed she/he had three medications amiodarone (antiarrhythmic), losartan (treats hypertension) and metoprolol (treats hypertension) on 4/15/26 scheduled at 8:00 AM. On 4/20/26 at 11:47 AM, Resident 45 stated she/he usually only took three pills in the morning. The resident stated when the nurse handed her/him more than three pills on 4/15/26 between 8:00 AM and 8:30 AM, she/he said, This seems like a lot. Resident 45 stated the nurse informed her/him this was the amount she/he was supposed to take. Resident 45 stated she/he trusted staff to do the right thing, and consumed the medications. Resident 45 stated she/he felt very weak after receiving the medications.On 4/21/26 at 12:00 PM, Staff 14 (CNA) stated Resident 45 was usually alert, oriented and able to understand conversation and instructions. Staff 14 stated on the morning of 4/15/26, Resident 45 was very confused, not at her/his typical baseline and Staff 14 had to repeat instructions multiple times when providing cares to Resident 45. Staff 14 stated after she helped Resident 45 with showering, she was going to report Resident 45's behaviors but Staff 3 (RN/Infection Preventionist) approached her and instructed Staff 14 to lay Resident 45 down.On 4/21/26 at 12:45 PM, Staff 11 (LPN) stated he accidentally gave Resident 45 another resident's medications on the morning of 4/15/26. Staff 11 stated he was distracted with staff, residents and family and not accustomed to the area he was assigned to. Staff 11 stated he did not follow the five rights of medication (verify the right person, medication, dose, route, and time) when he handed medications to Resident 45. Staff 11 stated Resident 45 informed him she/he thought it seemed like she/he was being given a lot of medications and Staff 11 informed Resident 45 there was usually a lot of medications given in the morning. Staff 11 stated Resident 45 accepted the answer and consumed the medications. Staff 11 stated he realized his mistake and informed Staff 3 (RN/Infection Preventionist). Staff 11 stated Resident 45's vitals were checked a few times and she/he had very low blood pressure and the resident was sent out to the hospital for further evaluation.On 4/22/26 at 10:53 AM, Staff 3 (RN/Infection Preventionist) stated on the morning of 4/15/26, Staff 11 notified her of Resident 45 being given another resident's medication. Staff 3 stated she assessed Resident 45 and the resident's vitals were checked and Resident 45's blood pressure was very low. Resident 45 was sent to a hospital emergency department for further evaluation. A review of Resident 45's medication error report dated 4/15/26 revealed Resident 45 was administered 12 medications of another resident on 4/15/26 at 8:30 AM and Staff 11 realized the error at 10:09 AM.A review of Resident 45's hospital records from 4/15/26 through 4/17/26 revealed Resident 45 presented to the hospital with bradycardia (slow resting heart rate) and hypotension (low blood pressure often causing dizziness, fainting, and blurred vision) and was diagnosed with transient circulatory shock (a life-threatening failure of the cardiovascular system to deliver enough oxygen to tissues, leading to cellular hypoxia and organ dysfunction) secondary to unintentional medication overdose. Resident 45 arrived to the emergency department on 4/15/26, requiring admission to the intensive care unit and vasopressor support (a critical care intervention used to treat severe hypotension and shock).On 4/23/26 at 3:26 PM, Staff 2 (DNS) stated she was aware of the medication error that occurred on 4/15/26 and Resident 45 being sent out to the hospital for further evaluation. Staff 2 acknowledged Resident 45 was given another resident's medication and stated she expected staff to always follow the five rights of medication administration by ensuring the right resident, right medication, right dose, right route, and right time.The deficient practice was identified as Past Noncompliance based on the following:On 4/15/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the significant medication error:1. Staff 11 was immediately educated on 4/15/26.2. The deficient practice was brought to quality assurance and a plan of correction was implemented on 4/22/26, including weekly medication pass audits.3. Provision of a Medication Administration Training in-service to all licensed staff which outlined the process to ensure the correct drug, resident, dose, route and time prior to administering medications was completed on 4/24/26.4. Ongoing QAPI review and oversight.

Based on observation and interview it was determined the facility failed to ensure medication and treatment carts were locked and secured appropriately for 1 of 4 halls observed (200 Hall) during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications. Findings include:The facility's Security of Medication Cart policy dated 5/2010 included the following:- The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.- The cart must be locked before the nurse enters the resident's room.- Medication carts must be securely locked at all times when out of the nurse's view.On 4/20/26 at 2:40 PM, Staff 17 (RN) was observed alone standing next to an unlocked medication cart in the 200 Hall. At 2:42 PM, she walked away from the cart and out of the 200 Hall. At 2:42 PM, Staff 17 was observed locking the medication cart and stated the expectation was for medication carts to be locked whenever staff was away from it. Staff 17 stated she did not have the key to the medication cart, because she was not in charge of it. Staff 17 stated she could not find the person in charge of the cart and confirmed residents' prescribed medications were in the cart.On 4/21/26 at 12:34 PM, an unlocked treatment cart was observed in the 200 Hall. Staff 18 (LPN) and another staff member were observed to be in the bistro area of the 200 Hall, not within sight of the treatment cart. At 12:35 PM, Staff 18 confirmed the treatment cart was unlocked and stated the expectation was to lock medication and treatment carts anytime he walked away from them. The treatment cart was observed to contain insulin and needles.On 4/23/26 at 3:11 PM, an unlocked medication cart was observed in the 200 Hall. At 3:12 PM, Staff 19 (RN) confirmed the cart was unlocked. Staff 19 confirmed residents' prescribed medications were in the medication cart. Staff 19 stated she was distracted and was more accustomed to working during the night shift. She stated the expectation was to lock medication and treatment carts whenever she walked away from them.On 4/23/26 at 3:39 PM, Staff 2 (DNS) stated she expected staff to lock medication and treatment carts whenever staff were away from the medication and treatment carts for safety purposes.

Based on observation, interview, and record review it was determined the facility failed to ensure hand hygiene was performed during wound care for 1 of 1 sampled resident (#7) reviewed for pressure ulcer. This placed residents at risk for cross contamination. Findings include: Resident 7 was admitted to the facility in 3/2026 with a diagnosis of diabetes. The facilities Standard Precautions policy and procedure last revised 5/2010 revealed hand hygiene (washing hands with soap and water or an alcohol-based hand rub), was to be performed when hands were not visibly soiled and gloves were to be changed, as necessary, during care of a resident to prevent cross-contamination when moving from a dirty site to a clean site. On 4/21/26 at 11:14 AM Staff 15 (LPN) was observed to remove Resident 7's old pressure ulcer dressing and adjusted Resident 7's incontinent brief. Staff 15 was stopped by this surveyor prior to him cleaning Resident 7's pressure ulcer. Staff 7 stated he should have changed gloves when going from a dirty task to a clean task. Staff 7 then removed her/his gloves and prior to putting on clean gloves was stopped by this surveyor to ensure hand hygiene was performed. Staff 15 stated he should have performed hand hygiene prior to putting on clean gloves. On 4/24/26 at 9:15 AM Staff 2 (DNS) stated staff were to follow infection control standards including changing gloves as needed and preforming hand hygiene when gloves were removed.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 1 of 1 sampled residents (#9) reviewed for accident hazards. This placed resident at risk for unsafe medication administration. Findings include:The facility's Self-Administration of Drugs policy dated 5/2010 included the following:- Staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications.- Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents.- Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage.Resident 9 was admitted to facility in 5/2010 with diagnosis of end stage renal disease (permanent chronic kidney failure).The Quarterly MDS with an ARD of 3/7/26 revealed Resident 9 had a BIMS score of 14, which indicated the resident was cognitively intact.A review of Resident 9's clinical record revealed no current self-administration of medication assessment was completed to determine the resident's ability to safely self-administer medications.Observations on 4/20/26 at 1:35 PM and 4/21/26 at 11:32 AM revealed Resident 9 had a large weekly pill organizer for Monday through Sunday, three times per day sitting on her/his bedside table, with 16 of 21 slots filled with pills.On 4/20/26 at 1:35 PM, Resident 9 stated the pill organizer had been on her/his bedside table for about a week. The resident stated she/he was out of the facility on a planned trip and did not take all of the pills in her/his pill organizer while she/he was out of the facility on her/his trip.A review of Resident 9's progress notes revealed she/he went out of the facility on 2/10/26 with packed medications and returned to the facility on 2/16/26.On 4/21/26 at 1:29 PM, Staff 14 (CNA), at 1:31 PM, Staff 15 (CNA) and at 2:23 PM, Staff 16 (CNA) stated they were unaware of any residents who were authorized to self-administer medications. Staff stated if medications were found on residents' bedside tables, they would inform a nurse.On 4/21/26 at 2:24 PM, Staff 12 (RN) stated staff were expected to inform a nurse if medications were observed in a resident's room. Staff 12 stated the protocol was to check in with residents after their return from a prolonged trip, which included asking about the status of medications that were packed. Was this RN aware of Resident 9's medications- if so please include here.On 4/21/26 at 2:35 PM, Staff 13 (LPN) stated he did not notice Resident 9's pill organizer the first time he entered Resident 9's room on 4/21/26 to give morning medications. Staff 13 stated he saw the pill organizer on Resident 9's bedside table when he entered Resident 9's room for the second time on 4/21/26 at 11:40 AM. He stated the pill organizer had pills from when Resident 9 went on a trip a few months ago. Staff 13 stated he removed the pill organizer from the Resident 9's room because she was not assessed for self-administration of medications.On 4/23/26 at 3:26 PM, Staff 8 (RNCM) acknowledged Resident 9 was not assessed for self-administering medications and stated she expected CNAs to inform nurses if medications were found to be in a resident's room. Staff 8 stated medications should be in a locked location and not out in the open. She stated when residents were packed medications on an outing, the protocol was for nurses to check in and inquire about the medications when residents return to the facility. Staff 8 stated a process and assessment was involved in order for residents to self-administer medications.On 4/23/26 at 3:34 PM, Staff 2 (DNS) stated she expected staff to inform a nurse immediately if medications were found by a resident's bedside. She stated a process and assessment was involved in order for residents to self-administer medications.

Based on interview and record review it was determined the facility failed to ensure a resident's advance directive was filed in her/his clinical record for 1 of 1 sampled resident (#5) reviewed for advance directive. This placed residents at risk for end-of-life choices not being honored. Findings include: Resident 5 was admitted to the facility in 12/2025 with a diagnosis of cancer. Resident 5's 12/22/25 admission MDS revealed she/he was cognitively intact. Resident 5's 3/26/26 Multidisciplinary Care Conference revealed she/he and her/his family participated in the care conference. The care conference notes indicated Resident 5 had an advance directive and family was to provide a copy to the facility. Resident 5's clinical record revealed her/his advance directive was not filed. On 4/22/26 at 10:00 AM Resident 5 stated she/he had an advance directive. On 4/22/26 at 8:24 AM Staff 4 (Social Services) stated if a resident had an advance directive, she was to ensure family provided the advance directive to the facility. Staff 4 stated she did not follow-up with Resident 5's family. On 4/23/26 at 8:50 AM Staff 5 (Social Service's Director) stated if a resident had an advance staff were to follow-up with family to ensure it was in a resident's clinical record and staff were to document attempts to call family. On 4/24/26 at 8:57 AM Staff 1 (Administrator) stated if a resident had an advance directive staff should ensure it was in the clinical record as soon as able.

Based on interview and record review it was determined the facility failed to notify a resident representative after a change of condition for 1 of 1 resident (#87) reviewed for notifications. This placed residents at risk for uninformed healthcare decisions. Findings include:Resident 87 was admitted to the facility in 11/2024 with diagnoses including surgical treatment after a hip fracture, dementia, and anxiety disorder.A Resident Designation Form from 11/8/24 stated Resident 87 elected to have Witness 2 contacted in case of emergency.A Skilled Nursing Progress Note from Staff 21 (LPN) 12/3/24 revealed Resident 87 had the onset of a new possible infection at the surgical site of her/his left hip. Staff 23 (Nurse Practitioner) and Staff 22 (RNCM) were notified of this change of condition. Staff 23 directed Staff 21 to start Resident 87 on cephalexin, (an antibiotic).A 12/3/24 Physician Order directed cephalexin to be started on 12/3/25 to address Resident 87's suspected wound infection.Review of the 12/2025 MAR revealed Resident 87 started on an antibiotic, cephalexin, on the evening of 12/3/25.A 12/5/24 progress note revealed Staff 22 (RNCM) contacted Resident 87's family regarding the suspected infection and starting an antibiotic.On 4/22/26 at 2:49 PM Witness 2 (Family Member) stated she/he requested to be notified of any change of condition experienced by Resident 87. Witness 2 stated she/he was not notified on 12/3/24 when Resident 87's had a suspected infection at the surgical site at her/his left hip. On 4/23/26 at 11:04 AM Staff 21 stated she made the Resident Care Manager aware of the suspected infection and was not aware if Resident 87's family was notified of Resident 87's change of condition.On 4/23/26 at 11:51 AM Staff 22 stated family members were contacted when a resident experiences a change of condition. Staff 22 confirmed Resident 87 was suspected to have a wound infection, and treatment was started to treat the infection on 12/3/24, but Resident 87's emergency contact was not alerted of Resident 87's change of condition until 12/5/24.On 4/23/26 at 12:29 PM Staff 2 (DNS) confirmed she would consider a potential infection a change of condition which required notification to a resident's emergency contact and Resident 87's emergency contact should have been contacted on 12/3/24.

Based on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for 1 of 1 sampled resident (#86) reviewed for abuse. This placed residents at risk for continued depravation of goods and services. Findings include:Resident 86 admitted to the facility in 7/2025 with diagnoses including right femur fracture and major depressive disorder. The 7/31/25 admission MDS assessed Resident 86 as cognitively intact. The facility submitted a Facility Reported Incident (FRI) on 8/16/25 indicating Resident 86 received fraud alerts from her/his financial institutions and discovered two credit cards and one debit card missing. Resident 86 reported Staff 10 (Former Maintenance Assistant) had entered her/his room multiple times over the prior weeks without clear request, reportedly to check equipment. Interview with the resident's family and record review revealed fraudulent charges between 8/4/25 and 8/16/25 totaling over $1300, including a charge at a gas station in the same town where Staff 10 resided as well as miscellaneous online purchases. The employee was placed on immediate administrative leave.The facility's investigation revealed video surveillance footage confirmed Staff 10 utilized the resident's credit and debit cards at a local gas station and for miscellaneous online purchases. The facility also obtained footage of Staff 10 entering Resident 86's room on multiple occasions without a documented work order or request for maintenance services. Law enforcement was notified, and a police report was filed. The facility reimbursed Resident 86 for the fraudulent charges. A facility-wide audit was conducted to determine if other residents experienced missing property, no additional concerns were identified.Resident 86 experienced financial loss exceeding $1300 and emotional distress related to the unauthorized use of her/his personal financial accounts, which resulted in her/him electing to move rooms due to concerns for personal safety and security. On 4/21/26 at 10:24 AM Witness 1 (Family Member) confirmed the cards were kept in Resident 86's room and no permission had been given for anyone to use them. Witness 1 stated Resident 86 elected to move from her/his private room to another private room following the incident for an increased sense of security. On 4/23/26 at 9:45 AM Staff 2 (DNS) confirmed she was aware of the incident which occurred on 8/16/25 regarding Resident 86 and misappropriation of funds had occurred. Staff 2 stated it was her expectation residents were protected from misappropriation and staff did not take or utilize resident property. On 4/23/26 at 9:50 AM Staff 9 (Former Administrator) confirmed misappropriation of funds occurred on 8/16/25 regarding Resident 86 and stated Staff 10 was immediately removed from the schedule, reported to law enforcement, and subsequently terminated. Staff 9 stated she expected staff to immediately report any misappropriation concerns and always protect resident property. Staff 9 further stated the facility offered lockboxes to residents for personal belongings, and residents retain the key for added security. On 4/23/26 at 10:26 AM Staff 1 (Administrator) confirmed the 8/16/25 incident occurred and Resident 86 had funds stolen and used by Staff 10. Staff 1 stated immediate actions was taken to address the misappropriation of funds. Staff 1 stated she expected resident property was protected and staff immediately report allegations of misappropriation. On 4/24/26 at 8:57 AM Staff 10 stated he did not provide a statement regarding the allegation of resident stolen property. Staff 10 confirmed he was placed on administrative leave and was subsequently terminated. The incident met the criteria for past noncompliance as follows:The deficient practice was identified as Past Noncompliance based on the following:-On 8/16/25, the deficient practice was identified by the facility, and the facility completed a root cause analysis of the incident and determined misappropriation of funds occurred. The plan of correction included:1. Staff 10 was placed on leave pending the investigation and was subsequently terminated. 2. Staff were provided with in-services training including reeducation regarding abuse and misappropriation of funds and all required training was completed by 9/10/25.3. Audits were conducted to ensure ongoing compliance and staff adherence to appropriate practices regarding misappropriation of funds. 4. Ongoing Quality Assurance oversight.

Based on interview and record review it was determined the facility failed to ensure the State Long-Term Care Ombudsman office was notified of a resident's discharge for 1 of 1 sampled resident (#85) reviewed for discharge. This placed residents at risk for lack of advocacy. Findings include: Resident 85 was admitted to the facility in 2/2026 with a diagnosis of respiratory failure. Resident 85's Clinical record revealed she/he was discharged in 2/2026. Resident 85's clinical record did not reveal the State Long-Term Care Ombudsman office was notified of her/his discharge. The facility's 1/1/26 through 3/31/26 Discharges list revealed Resident 85 was not listed as a discharged resident. On 4/23/26 at 8:58 AM Staff 6 (Business Office Manager) verified the 1/1/26 through 3/31/26 Discharge list did not include Resident 85, and this list was sent to the Ombudsman office to notify them of the facility discharged residents. On 4/24/26 at 8:57 AM Staff 1 (Administrator) stated a complete list of discharged residents were to be sent to the Ombudsman office.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident's oxygen equipment was cleaned for 1 of 1 sampled resident (#5) reviewed for respiratory care. This placed residents at risk for decreased oxygen quality. Findings include: Resident 5 was admitted to the facility in 12/2025 with a diagnosis of a stroke. Resident 5's Task form for cleaning her/his oxygen filter indicated on 4/17/26 staff cleaned her/his oxygen filter. On 4/20/26 Resident 5's oxygen filter was observed with gray/brown dust coating the filter. On 4/22/26 at 8:11 AM Staff 7 (CNA) stated the nurses were responsible for cleaning the oxygen filters. On 4/22/26 at 8:19 AM Staff 21 (LPN) stated the oxygen company managed the oxygen equipment. On /22/26 at 11:44 AM Staff 8 (RNCM) verified Resident 5's oxygen filter was coated with dust and the amount of dust present likely did not build up after 4/17/26. On 4/24/26 at 9:15 AM Staff 2 (DNS) stated staff were to clean the oxygen filters weekly.

Based on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 4 halls reviewed for infection control. This deficient practice was determined to be an immediate jeopardy situation and placed residents at risk for contracting COVID-19. Findings include: The CDC's 3/6/24 Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/viral-respiratory-prevention/index.html, specified health care personnel are advised to apply appropriate Transmission-Based Precautions when providing care to a patient with known or suspected respiratory infection. Infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection included to use Droplet Precautions with patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing or talking. Use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection worn during all patient care encounters. Remove face protection before room exit. The CDC's 9/2024 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings website, https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html, and the facility's 3/2024 Policy for Isolation - Categories of Transmission Based Precautions specified in all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing transmission. When this is not possible, adequately clean and disinfect the items after each use and before use for another resident. On 1/27/25 and 1/28/25 between the hours of 6:59 AM and 4:24 PM the following observations and interviews occurred: - Rooms 302, 305, 307, 312, 315, 404, 405, 413, 414 and 417 were identified as Transmission Based Precautions (TBP) rooms where COVID-19 positive residents resided. - Staff 20 (CNA) exited room [ROOM NUMBER] with a respirator on her face and goggles on top of her head. Staff 20 removed the goggles with bare hands, placed the goggles in a pocket, removed the respirator and crinkled it into her hand, obtained a new respirator from a package of unused respirators while holding the contaminated respirator in the same hand, and donned the clean respirator. Staff 20 did not perform hand hygiene during the process. - While preparing to enter room [ROOM NUMBER], Staff 23 (LPN) donned a gown and gloves and did not don a new respirator and did not don eye protection. Staff 23 entered room [ROOM NUMBER] and provided close-contact direct care. Staff 23 exited the room, doffed the gown and gloves and did not doff the respirator. Staff 23 stated she was unsure if she needed eye protection during care for a resident known to be infected with COVID-19. Staff 23 stated she did not believe she needed to remove the respirator upon exit of a TBP room and stated the mask needed to be changed only when visibly soiled. - Staff 23 entered room [ROOM NUMBER] with gown, gloves, respirator and face shield. Upon exit, Staff 23 held the used face shield in her bare hands, did not remove or change the respirator and walked down the hall to the treatment cart. Staff placed the used face shield on the treatment cart without a barrier and did not disinfect the shield. Without changing the respirator used in room [ROOM NUMBER], Staff 23 entered room [ROOM NUMBER], a non-COVID-19 room, and provided close contact care. - Staff 24 (CNA) approached room [ROOM NUMBER] with a respirator and eye glasses donned. Staff 24 donned a gown and gloves and picked up a clear plastic bag from the floor which contained a blood pressure cuff, stethoscope, thermometer and oximeter (used to measure blood oxygen levels). Staff 24 entered room [ROOM NUMBER], removed the vitals equipment from the bag and placed the pieces directly on the resident's bed. Staff 24 obtained the resident's vital signs using the various pieces of equipment, placed the thermometer, oximeter and cuff back into the bag and placed the stethoscope around her neck. Staff 24 did not disinfect the equipment at any time during the process. Staff 24 exited the room after doffing the gown and gloves, did not remove the N95 or eye glasses and had the stethoscope draped around her neck. Staff 24 walked down the hall to the nursing station, placed the bag of vitals equipment directly on the counter, donned gloves and wiped the oximeter and thermometer with an alcohol prep pad. Staff 24 did not remove and disinfect the stethoscope and did not change the respirator. Staff 24 stated she did not remove the glasses between resident cares and left them on throughout the entire shift. Staff 24 stated she used the same vitals equipment for all of the residents on the 400 hall, including those residents not infected with COVID-19. - Staff 25 (RN) doffed his respirator, did not perform hand hygiene, donned a new respirator, did not don eye protection and then entered room [ROOM NUMBER]. Staff 25 stated he forgot to don eye protection and stated when he wore eye protection, he used the face shield which hung on the treatment cart in the hallway. - Staff 22 (CNA) stated she thought it was okay to store the used face shields in the PPE storage containers which hung on the room door and the face shields were shared with other staff. - Staff 9 (CNA) exited room [ROOM NUMBER], doffed the face shield and placed the used face shield inside the storage container with clean, unused PPE. Staff 9 stated she left the respirator on upon exit and stated she wore the same respirator in and out of resident rooms and at the nursing station. - Staff 26 (Physical Therapy Assistant) entered room [ROOM NUMBER], wore a respirator and did not don a gown, gloves or face shield. Staff 26 stated he was supposed to don PPE before entering but did not because he checked on the resident real quick. Staff 26 did not doff the respirator upon exit and continued to wear the same respirator throughout the hall. - Staff 27 (Physical Therapist) exited room [ROOM NUMBER] with a respirator and face shield donned. Staff 27 walked to a treatment cart at the end of the hall, donned gloves, removed the face shield, cleaned the shield with a disinfectant wipe, doffed the gloves, performed hand hygiene, tucked the used face shield between her side and arm and walked down the hallway. - Used face shields were stored on name placards outside of TBP rooms. - Used face shields were stored inside PPE storage containers, in contact with clean, unused PPE. - Used face shields were stored on medication and treatment carts in the 200, 300 and 400 hallways. On 1/28/25 at 8:29 AM and 9:55 AM Staff 2 (DNS) and Staff 3 (DNS in training) stated if a resident room was identified on TBP for COVID-19, staff were expected to don the required PPE before crossing through the doorway of the room. Staff 2 and 3 stated appropriate PPE included a gown, gloves, respirator and face shield which should be donned prior to entrance and doffed upon exit. Staff 2 and 3 indicated all PPE worn in a TBP room was considered contaminated and was to be discarded upon exit. Staff 2 and 3 stated they expected staff to don a new respirator right away and the same respirator was not worn in other rooms. Staff 2 indicated there was an abundance of face shields readily accessible and available and goggles were not an acceptable form of eye protection in a TBP room. Staff 2 stated she expected face shields were not shared between staff or used between resident care. She stated if face shields were reused by a single staff, she expected staff to disinfect the shield with the appropriate disinfectant between uses and store the used face shield in the PPE container. Staff 2 stated each TBP room was supplied with a dedicated stethoscope stored inside the room and was used on that resident only. She indicated if resident care equipment was shared among residents, the expectation included the equipment was disinfected with the appropriate product between every resident. Staff 2 acknowledged there was a risk of contamination and spread of infection if staff did not remove potentially contaminated PPE after resident care in a TBP room. Staff 2 stated the facility's first case of COVID-19 was identified on 1/9/25. On 1/28/25 at 12:00 PM Staff 1 (Administrator), Staff 2, Staff 3 and Staff 28 (Administrator in training) were informed the facility's failure to implement appropriate infection control during a COVID-19 outbreak constituted an Immediate Jeopardy situation. An IJ removal plan was requested. On 1/28/25 at 3:21 PM an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: 1. Immediate staff training was initiated by the DNS and Administrator on COVID transmission protocols, proper use of PPE (donning, doffing and reuse), storage and handling of PPE, disinfecting and use of equipment. 2. Staff who received training included CNAs, nurses, housekeeping, laundry, maintenance, administrative staff, agency staff and contracted staff. 3. Staff training was done immediately for all staff in the facility then at each shift change on 1/28/25. 4. Documentation of training would include a sign in sheet and a PPE competency validation form. 5. Continued training would be conducted at each shift change and/or 1:1 until all staff received training. 6. For staff who were on leave, training would be provided prior to returning to work. 7. Facility will have a quality assurance meeting with the committee (Medical Director, Infection Preventionist, DNS, Administrator and other interdisciplinary members) on 1/28/25 to review policies and procedures on TBP and COVID-19 precautions, including proper use of PPE, storage and equipment use. 8. DNS and Infection Preventionist will conduct visual audits every shift for three days, then weekly for four weeks, then monthly ongoing to ensure continued compliance with COVID and TBP requirements. 9. Audits will be reviewed by the quality assurance team monthly for six months to ensure ongoing compliance. On 1/29/25 at 9:54 AM it was determined the immediacy was removed after verification of completion of the IJ removal plan. 47000

Based on observation, interview and record review it was determined the facility failed to develop and implement a care plan related to the use of hearing aids for 1 of 1 sampled resident (#269) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: Resident 269 was admitted to the facility in 1/2025 with diagnoses including respiratory failure. In an interview on 1/27/25 at 10:26 AM, Witness 2 (Family Member) stated Resident 269 wore hearing aids during the day and needed assistance to charge them at night. Witness 2 stated when she/he visited the resident every morning the resident's hearing aids were still in her/his ears and were not charged. A review of Resident 269's care plan revealed no information related to use of hearing aids. On 1/28/25 at 8:43 AM, Resident 269 was observed sitting on her/his bed with one hearing aid in her/his left ear. The other hearing aid was in a charging device, located on the resident's nightstand. During an observation and interview with Resident 269 and Witness 2 on 1/29/25 at 10:21 AM, the resident's hearing aids were on the charging station blinking green. Witness 2 stated when she arrived the hearing aids were still in the resident's ears, and Witness 2 removed the hearing aids and placed them in the charging station. Witness 2 stated when the green light was blinking it indicated the hearing aids were not charged. On 1/29/25 at 11:29 AM, Staff 29 (CNA) and Staff 7 (LPN) were present for an interview. Staff 29 stated she provided care for Resident 296's hearing aids based upon what instructions were indicated in the resident's care plan. Staff 7 reviewed the resident's care plan and found no information related to the resident's hearing aids. On 1/30/25 at 12:35 PM, Staff 2 (DNS) confirmed the care plan lacked information related to the resident's use of hearing aids.

Based on observation, interview and record review it was determined the facility failed to provide appropriate foot care for 1 of 1 sampled resident (#6) reviewed for skin conditions. This placed residents at risk for lack of nail care and increased infections. Findings include: Resident 6 was admitted to the facility in 8/2024 with diagnoses including diabetes. Resident 6's 8/11/24 Admission MDS revealed the resident was cognitively intact. Resident 6's 10/29/24 Physician Orders indicated the resident was to be seen by a podiatrist for onychomycosis (a fungal infection of the nails) and diabetic foot care. An 11/19/24 Social Services Note revealed a message was left with the podiatrist to get follow up regarding the scheduling of Resident 6's podiatry appointment. A 1/8/25 Physician Encounter Note completed by Staff 13 (Medical Director) indicated the resident had a referral to be seen by a podiatrist from 10/29/24. No evidence was found in Resident 6's clinical record to indicate additional efforts to schedule a podiatry appointment for the resident were made after 11/19/24. On 1/29/25 at 12:54 PM Resident 6 was observed in her/his room. Resident 6 stated she/he had a wound on her/his right foot but was unsure if she/he needed to see a podiatrist. On 1/29/25 at 3:28 PM Staff 5 (Social Services Director) stated the last time she tried to schedule a podiatry appointment for Resident 6 was on 11/19/24. On 1/29/25 at 3:44 PM Staff 11 (RNCM) stated there was no follow up since November regarding the scheduling of Resident 6's podiatry appointment, and she recently spoke with Staff 14 (NP) who indicated she still wanted the resident to be seen by a podiatrist.

Based on observation, interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#6) reviewed for PASARR (Pre-Admission Screening and Resident Review). This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: The facility's 5/2023 Trauma Informed Care Policy indicated the following: -Nursing staff, Social Services and the attending physician were to identify individuals with a history of trauma, as the resident was willing to disclose, as part of an initial assessment. Information could also be gathered from family and friends in order to identify and implement person-centered trauma-informed care. -Areas of potential life trauma were to be identified and developed into a person-centered care plan based on the Social Services Admission Assessment. This Assessment was to gather how trauma impacted the resident's care needs and triggers in addition to the resident's treatment history and/or a specialist that may have been involved in the care/support of the resident's trauma needs/PTSD (Post-traumatic stress disorder). -If the resident was treated for past trauma, facility staff and the provider would obtain and document ongoing reassessments of changes in the individual's behavior, mood and function no less than quarterly. -Staff were to document via Quarterly Social Services Assessment and/or in the MDS CAA interventions attempted and outcomes associated with person-centered trauma-informed interventions. Admission records received by the facility on 7/29/24, prior to Resident 6's admission to the facility, revealed the resident had an active diagnosis of PTSD. Resident 6 was admitted to the facility in 8/2024 with diagnoses including bipolar disorder (a chronic mental health condition characterized by extreme mood swings and caused by a complex interplay of multiple factors, including genetics, brain chemistry, psychological factors, other medical conditions and environmental factors such as trauma) and PTSD. Resident 6's 8/5/24 Social Services Admission Assessment revealed the resident chose not to share when asked if she/he experienced any traumas, such as war. Resident 6's 8/11/24 Admission MDS revealed the resident was cognitively intact. No evidence was found in Resident 6's clinical record to indicate staff were aware of the resident's diagnosis of PTSD or attempted to follow-up with the resident, the resident's family members, or medical providers, related to the resident's diagnosis of PTSD. On 1/27/25 at 11:31 AM Resident 6 was observed in her/his room. Resident 6 tearfully recounted times when she/he witnessed and experienced extreme violence, and indicated facility staff did not ask about her/his history of trauma. On 1/29/25 at 12:54 PM Resident 6 was observed in her/his room and described her/his current leg infection to the state surveyor. Unprompted by the state surveyor, Resident 6 changed the conversation to the topic of the extreme violence she/he witnessed and experienced in the past. On 1/29/25 at 1:11 PM Staff 21 (CNA) stated Resident 6 had bad days when she/he got sad. Staff 21 was unaware of any potential trauma triggers for the resident. On 1/29/25 at 1:36 PM Staff 22 (CNA) did not express awareness of Resident 6's history of trauma. On 1/30/25 at 10:52 AM Staff 5 (Social Services Director), Staff 4 (Social Services Director) and Staff 11 (RNCM) were present for an interview. Staff 5, Staff 4 and Staff 11 stated they were unaware of Resident 6's diagnosis of PTSD and did not reapproach the resident about her/his history of trauma following her/his admission to the facility or reach out to family, friends or providers for additional information about the resident's PTSD and potential trauma triggers. On 1/30/25 at 12:46 PM Staff 2 (DNS) stated residents with a diagnosis of PTSD were to have a related care plan and staff were to reach out to family members when residents declined to discuss their trauma.

Based on observation, interview and record review it was determined the facility failed to provide treatment and services to correct ongoing signs of depressive behavior for 1 of 1 sampled resident (#49) reviewed for behavioral-emotional needs. This placed residents at risk for unmet behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's undated Behavioral Assessment for Un-Met Needs/Psychoactive Medications Policy indicated the following: -A Behavior UDA (assessment) was to be opened by the Social Services Director at the time a new behavior was noted and completed by the interdisciplinary team to ensure environmental/facility practices or medical/clinical causes of behavior, non-pharmacological interventions implemented and delirium were ruled out before the initiation of a medication/increased dosing. -If the physician/NP initiated a psychoactive medication, the RNCM was to follow up with the prescriber regarding the continued use of the medication. If the medication was not discontinued, the Social Services Director was to open a Behavior UDA within 72 hours of the medication start date. -If a resident had active behaviors upon admission, the Behavior UDA was to be completed by day 14 with the MDS. Resident 49 was admitted to the facility in 12/2024 with diagnoses including orthopedic aftercare following a surgical amputation and adjustment disorder (a mental health condition that develops as an unhealthy response to a stressful life event) with anxiety and depressed mood. Resident 49's 12/13/24 Social Services Admission Assessment indicated the loss of the resident's leg had her/him feeling down. A 12/17/24 Encounter Note written by Staff 14 (NP) revealed Resident 49 admitted to the facility following a hemipelvectomy (a surgical procedure that involved the removal of half of the pelvis bone and the lower extremity on that side). The note further revealed the resident experienced an increase in irritability, nervousness, anxiety, agitation and depressive mood as well as a lack of motivation in response to her/his amputation. She/he declined treatment with an antidepressant and had lorazepam (a medication used to treat anxiety and sleeping problems related to anxiety) available PRN. Resident 49's 1/10/25 Admission MDS revealed the resident was cognitively intact and felt down, depressed or hopeless several days over the previous two weeks. No evidence was found in Resident 49's clinical record to indicate any behavioral health services were offered, an individualized care plan was developed or ongoing monitoring of the resident's mood was completed in order to ensure her/his emotional and psychosocial needs were addressed and met. On 1/27/25 at 4:52 PM Resident 49 was observed in her/his room accompanied by Witness 1 (Family Member). Resident 49 stated she/he was more depressed now than [she/he] had ever been on account of her/his recent amputation. Resident 49 stated she/he was open to any kind of non-pharmacological psychosocial intervention, including counseling, but no one at the facility offered any psychosocial support. Witness 1 stated there was no mood support in the facility which did not make sense with residents like [Resident 49] coping with traumatic losses. On 1/29/25 at 1:11 PM Staff 21 (CNA) stated Resident 49 seemed sad and depressed at times but was not sure why or what to do about it. On 1/30/25 at 10:38 AM Staff 4 (Social Services Director) stated Resident 49 was depressed since she/he had her/his leg amputated. Staff 4 stated the resident coped with multiple losses and did not recall if she offered any psychosocial supports to the resident.

Based on observation, interview and record review it was determined the facility failed to ensure a medication administration error rate of less than 5%. There were two errors in 29 opportunities resulting in a 6.9% error rate. This placed residents at risk for reduced medication efficacy and adverse medication side effects. Findings include: The 2023 insulin lispro Kwikpen Manufacturer Instructions For Use and the 2022 How to Use Lantus Pen Manufacturer Instructions specified the following: - to prime pen, turn the Dose Knob to select two units. Hold the pen with the needles pointing up, tap the pen gently to collect air bubbles at the top, continue holding pen with needle pointing up, push the Dose Knob in until it stops and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. Turn the Dose Knob to select the number of units needed. Always perform these safety steps before each injection. Resident 118 was admitted to the facility in 1/2025 with diagnoses including type 2 diabetes mellitus (impaired insulin production). Resident 118's 1/2025 Physician Orders included the following: - Insulin lispro injection solution, inject six units subcutaneously with meals; - Insulin glargine solution pen-injector, inject seven units subcutaneously in the morning. On 1/29/25 at 8:40 AM Staff 6 (LPN) was observed during Resident 118's medication administration. Staff 6 obtained Resident 118's insulin lispro Kwikpen (insulin pen) and dialed the dose knob until six units was observed in the dose window . Staff 6 did not perform the safety steps as indicated in the manufacturer's instructions. Staff 6 obtained Resident 118's Lantus insulin glargine Kwikpen (insulin pen) and dialed the dose knob until seven units was observed in the dose window. Staff 6 did not perform the safety steps as indicated in the manufacturer's instructions. Staff 6 gathered the Kwikpens and administered the insulin to the Resident. On 1/29/25 at 9:11 AM Staff 6 stated he was unaware if preparation of insulin Kwikpens included the safety steps for priming. Staff 6 acknowledged he did not perform the safety steps prior to administration of Resident 118's insulin. On 1/29/25 at 11:33 AM Staff 2 (DNS) was notified Resident 118's insulin Kwikpens were not primed and the safety steps were not followed prior to administration. Staff 2 stated she expected staff to follow the safety steps for priming prior to insulin Kwikpen administration.

Based on observation, interview and record review it was determined the facility failed to accurately code the MDS for 2 of 2 sampled residents (#s 6 and 65) reviewed for dental care and hospitalization s. This placed residents at risk for unmet care needs. Findings include: 1. The facility's 8/2017 Resident Assessment Instrument MDS 3.0 Policy indicated information derived from the comprehensive assessment enabled staff to plan care to allow the resident to reach her/his highest practicable level of functioning and included an assessment of the resident's dental status and the need for, and use of, dentures or other dental appliances. Resident 6 was admitted to the facility in 8/2024 with diagnoses including kidney failure. Resident 6's 8/5/24 Nursing Admission Assessment indicated the resident had a full upper and lower set of dentures. Resident 6's 8/11/24 Admission MDS revealed the resident was cognitively intact and not edentulous (without teeth). Resident 6's 8/24/24 Dental Care Plan indicated the resident had her/his natural teeth. On 1/27/25 at 12:07 PM Resident 6 was observed in her/his room and sat in her/his wheelchair. Resident 6 was observed to be edentulous, and the resident stated she/he was without teeth for over a decade. On 1/29/25 at 3:44 PM Staff 11 (RNCM) stated Resident 6's Admission MDS was coded in error as the resident admitted to the facility without teeth. On 1/30/25 at 12:33 PM Staff 2 (DNS) confirmed Resident 6's 8/11/24 Admission MDS was coded inaccurately. 39632 2. Resident 65 was admitted to the facility in 11/2024 with diagnoses including UTI. Resident 65's 12/20/24 Discharge Return Not Anticipated MDS coded the resident as hospitalized . Resident 65's 12/20/24 Discharge Progress Note indicated the resident discharged home. On 1/31/25 at 3:08 PM Staff 2 (DNS) reviewed Resident 65's health record and confirmed the resident discharged home on 12/20/24. Staff 2 acknowledged the 12/20/24 Discharge MDS was incorrectly coded as hospitalized and did not accurately reflect the resident's discharge location.

1. Based on observation, interview and record review it was determined the facility failed to ensure adequate hand hygiene during medication administration for 3 of 9 sampled residents (#s 33, 41 and 161) reviewed during medication administration. This placed residents at risk for spread of infection. Findings include: The facility's 5/2020 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infection. Employees must perform hand hygiene before and after direct contact with a resident or their immediate environment. On 8/24/23 at 2:26 PM Staff 3 (LPN) dispensed and administered Resident 41's medication in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. On 8/24/23 at 2:36 PM Staff 3 dispensed and administered Resident 33's medications in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. On 8/24/23 at 2:44 PM Staff 3 dispensed and administered Resident 161's medications in the resident's room. Staff 3 did not perform hand hygiene before or after she dispensed and administered the medication. On 8/24/23 at 2:50 PM Staff 3 stated she usually performed hand hygiene between residents but forgot to perform hand hygiene before and after the residents' medication administration. On 8/25/23 at 10:48 AM Staff 2 (DNS) Staff 2 was informed of Staff 3's lack of hand hygiene during medication administration and stated staff should perform hand hygiene between each resident and upon entrance and exit of each resident's room. 2. Based on observation, interview and record it was determined the facility failed to ensure provision of hand hygiene to residents prior to meal service for 1 of 4 halls reviewed for food service. This placed residents at risk for an unsanitary dining experience and the spread of infection. Findings include: The facility's 5/2020 Handwashing/Hand Hygiene Policy & Procedure specified hand hygiene was the primary means to prevent the spread of infection. Resident 159 was admitted to the facility in 8/2023 with diagnoses including aftercare following a joint replacement surgery and resided on the 100 hall. Resident 159's 8/13/23 Admission MDS indicated the resident was cognitively intact and required the assistance of staff for ADLs. Resident 21 was admitted to the facility in 8/2023 with diagnoses including chronic obstructive pulmonary disease (lung disease) and resided on the 100 hall. Resident 21's 8/14/23 Admission MDS indicated the resident was cognitively intact and required the assistance of staff for ADLs. On 8/22/23 at 9:13 AM Resident 159 stated staff did not offer or assist her/him with hand hygiene before meals. On 8/22/23 from 1:06 PM to 1:11 PM Staff 4 (Nursing Assistant), Staff 5 (Nursing Assistant Student) and Staff 6 (Nursing Assistant Student) passed the lunch meal trays to the 100 hall residents. Staff 4, Staff 5 and Staff 6 did not assist, provide or offer hand hygiene to the residents before or during the meal pass. On 8/22/23 at 1:13 PM Staff 5 and Staff 6 acknowledged they did not offer or provide hand hygiene to the 100 hall residents prior to passing the lunch meal trays. On 8/22/23 at 1:14 PM Staff 4 stated she offered residents hand hygiene after taking them to the bathroom and before meals. On 8/22/23 at 1:18 PM Resident 21 was in her/his room with the lunch meal on her/his table. Resident 21 stated she/he was not offered or provided with hand hygiene prior to this lunch meal and was not offered or assisted with hand hygiene before meals on a daily basis. On 8/22/23 at 1:25 PM Resident 159 was in her/his room with the lunch meal on her/his table. Resident 159 stated she/he was not offered or provided with hand hygiene prior to the lunch meal. On 8/25/23 at 10:48 AM Staff 2 (DNS) was notified the residents who resided on the 100 hall were not offered or provided with hand hygiene prior to the lunch meal on 8/22/23 and was informed Resident 21 and Resident 159 voiced concerns regarding the lack of hand hygiene. Staff 2 stated residents should be offered and assisted with hand hygiene as needed before meals.

Based on observation, interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) was posted in a prominent place readily accessible to residents and visitors on 3 of 3 days observed and failed to ensure postings were accurate for 7 of 28 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Multiple observations from 6/28/22 through 6/30/22 between the hours of 8:00 AM and 4:00 PM revealed the DCSDRs were in the back of a hanging wall file box located near the main nursing station, folded over so the posting was not visible to the residents or public. Review of the 6/1/22 through 6/28/22 DCSDRs indicated the following days when either the census, number of staff or hours worked were inaccurately recorded or required information was missing on daily postings: -6/1, 6/2, 6/3, 6/5, 6/6, 6/7 and 6/13. On 7/1/22 at 3:00 PM Staff 2 (Administrator-in-Training) confirmed the facility's failure to prominently post DCSDRs and accurately report required information.

Based on observation, interview and record review it was determined the facility failed to ensure the resident was assessed for safe self administration of medications for 2 of 2 sampled residents (#s 11 and 13) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 11 was admitted to the facility in 4/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at 10:40 AM, 6/29/22 at 8:50 AM and 3:31 PM and 6/30/22 at 8:41 AM Resident 11's room and bedside table were observed. An [MEDICATION(S)] inhaler (used to treat [CONDITION(S)]), [MEDICATION(S)] inhaler (used to treat wheezing and shortness of breath) and a [MEDICATION(S)] bottle (used to treat nasal congestion, sneezing and runny nose) were observed to be on Resident 11's bedside table and within the resident's reach. During these observations, Staff 6 (LPN), Staff 8 (RN) and Staff 9 (CNA) entered the resident's room, stood in close proximity to the bedside table and interacted with the resident. On 6/29/22 at 3:31 PM Resident 11 stated the inhalers were for emergencies and she/he used the inhalers when she/he felt the need. Resident 11 picked up the [MEDICATION(S)] and stated it was nose stuff and she/he used it about every day. On 6/29/22 at 4:29 PM Staff 7 (CNA) stated if she saw medications in a resident room, she would remove the medications and give them to the nurse. Staff 7 stated Resident 11 had inhalers in her/his room and the resident administered her/his inhalers. On 6/29/22 at 4:35 PM Staff 6 stated residents were unable to store medications in their room and self-administer medications unless an assessment was completed and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11's health record did not include a medication self-administration assessment or a self-administration physician order. On 6/30/22 at 9:13 AM Staff 4 (RNCM) stated a medication self-administration assessment was required in order for a resident to keep medications at the bedside to self-administer. Staff 4 stated the assessment was conducted to determine if a resident understood the medication and how and when to administer the medication. Staff 4 stated if a resident was approved for self-administration, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 4 reviewed Resident 11's health record and confirmed there was no medication self-administration assessment. Staff 4 stated she would not expect to find inhalers or [MEDICATION(S)] at Resident 11's bedside without an assessment and physician order. On 7/05/22 at 11:26 AM Staff 3 (DNS) was notified of the findings of this investigation. Staff 3 stated Resident 11's family brought in the inhalers and the resident kept them hidden. Staff 3 was notified the Antrovent and [MEDICATION(S)] inhalers and the [MEDICATION(S)] were in plain view on Resident 11's bedside table, within reach of the resident and Staff 6, Staff 8 and Staff 9 were observed in the resident's room several times. Staff 3 stated she expected the staff to see the medications and say something. Staff 3 stated a medication self-administration assessment should be completed to ensure safe self-administration and there should be an order in place from the provider before a resident self-administered any medications. 2. Resident 13 was admitted to the facility in 4/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at 2:00 PM, 6/29/22 at 3:05 PM and 6/30/22 at 9:54 AM, [MEDICATION(S)] (used for gastric upset) was observed on Resident 13's bedside table and Preparation-H (used to treat hemorrhoids) was observed on the window ledge. Resident 13 stated in an interview on 6/29/22 at 3:06 PM the medications were used for her/his occasional upset stomach, nausea and diarrhea. Review of Resident 13's health record revealed no assessment was completed to determine the resident's ability to safely self-administer the medications. On 6/30/22 at 2:32 PM Staff 4 (RNCM) confirmed Resident 13 was not assessed for safe self-administration of medications. On 7/1/22 at 10:40 AM Staff 3 (DNS) acknowledged the licensed nurses should have assessed Resident 13 for her/his ability to self-administer medications and obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review it was determined the facility failed to administer medications as ordered by the physician and failed to ensure surgical wound care ordered were clarified and standard nursing protocols for wound care were defined and transcribed for a resident with extensive surgical wounds for 2 of 2 sampled residents (#s 90 and 91) reviewed for medications errors and wound care.This placed the resident at risk for insufficient medication levels, delayed treatment, and worsening wounds. Findings include: 1. Resident 90 was admitted in 2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/30/21 Resident 90's physician ordered Epoetin Alpha 20,000 units/ml (a medication that stimulates red blood cell production) subcutaneously every seven days. Resident 90's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In a facility medication error report dated 6/11/21 Staff 17 LPN reported to Staff 18 (Resident Care Manager) the medication was not given because it was not available and indicated Staff 17 was unable to locate the medication which was stored in the medication refrigerator. A 6/11/21 progress note indicated Resident 90's physician was notified several days after not receiving the medications. Staff 17 was unavailable for an interview. Labs were obtained on 6/13/21 for Resident 90, after the missed doses were discovered. The labs indicated the resident's [CONDITION(S)] had worsened. Resident 90's physician ordered two iron infusions (a procedure in which iron is delivered through a vein) for the resident. On 6/30/21 at 11:40 AM Staff 3 (DNS) stated, although I was on vacation at the time, I would expect my nursing staff to follow the process. Contact the pharmacy, attempt to locate medication, check the Cubex and let the management or myself know. 2. Resident 91 was admitted to the facility in 2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital Skilled/Intermediate Nursing Facility Transfer Order dated 2/22/22 indicated Resident 91 was discharged from the hospital with orders for Wound Care: follow standard nursing protocols for wound care and follow up with podiatry in one week for wound check. The orders did not define standard nursing protocols for wound care. A facility Skin and Wound Evaluation dated 2/23/22 indicated Resident 91 admitted with a left poplitial fossa (leg area) surgical wound measuring 8.7 cm by 0.6 cm with staples (material used to close skin wounds) and a right inner thigh surgical wound measuring 36.3 cm by 4.4 cm. A review of Resident 91's 2/2022 and 3/2022 TARs indicated follow standard nursing protocols for wound care was provided every shift; however, did not define standard nursing protocol for wound care. On 6/28/22 at 12:14 PM Witness 1 (Complainant) reported facility staff did not appropriately care for Resident 91's surgical wounds, her/his surgical wound care fell through the cracks and they had to ask many times when the surgical wound staples would be removed. On 6/30/22 at 10:44 AM Staff 10 (RN) indicated that standard nursing wound care protocol orders were temporary orders used until specific orders were secured from a resident's provider. Staff 10 stated if they used the standard nursing protocol orders for wound care, they referred to a binder located at the main nursing station for guidance. On 7/5/22 at 9:52 AM Staff 6 (LPN) stated standard nursing wound care protocol orders were not appropriate to use for surgical wounds because surgical wounds required specific wound care orders since each wound was different; as an example some wounds had staples and other wounds had steri-strips. Staff 6 stated standard nursing wound care protocol orders were used for skin issues such as skin tears and were used temporarily, until specific orders were secured from the provider. Staff 6 stated if nursing used the standard nursing wound care protocols, the protocols were located in a binder at the main nursing station. On 7/5/22 at 11:41 AM Staff 4 (RNCM) stated standard nursing wound care protocols were located in a binder at the main nursing station. Staff 4 and surveyor reviewed the binder and no standard nursing wound care protocol was located for surgical wounds. This was confirmed by Staff 4. Staff 4 stated she could not locate any specific surgical wound care orders in Resident 91's medical records. On 7/6/22 at 2:01 PM and 3:26 PM Staff 2 (DNS) acknowledged the facility did not clarify Resident 91's surgical wound care orders and did not ensure standard nursing protocols for wound care orders were defined and transcribed. Staff 2 stated she was unable to state what treatment was completed for Resident 91's wounds based on the orders available.

Based on interview and record review it was determined the facility failed to implement care planned fall interventions for 2 of 3 sampled residents (Resident # 13 and 15) who had falls. Resident 15 sustained a leg fracture as a result of a fall. Findings include: 1. Resident 15 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. According to the care plan the resident could be physically aggressive during care. The care plan indicated two-persons were needed to assist the resident with transfers if the resident was agitated or aggressive. The care plan also indicated a gait belt should be used when transferring the resident. According to nurse's notes and an incident investigation, on 4/7/11 at 6:45 pm, the resident fell to the floor while being transferred from the wheelchair to bed. The investigation indicated Staff 1, CNA, was transferring the resident alone without using a gait belt. During the transfer the resident became combative and Staff 1 lowered the resident to the floor. The resident complained of right leg pain and was transported to the hospital where a [DIAGNOSES REDACTED]. The investigation indicated Staff 1 had not followed the resident's care plan for a two-person transfer using a gait belt. According to a documented interview with Staff 1, conducted on 4/8/11 by Staff 2, Administrator, Staff 1 stated that the resident was agitated before the transfer and became more agitated as the transfer proceeded. During the transfer Staff 1 lost her balance and the resident was lowered to the floor. Staff 1 indicated that she had a gait belt with her but did not use it during the transfer. Staff 1 indicated that she knew about the facility's gait belt policy. Staff 1 indicated that she had not looked at the resident's care plan which indicated the resident required a two-person transfer when agitated. In an interview on 4/25/11 at 11:00 am Staff 1 stated that she did not use a gait belt when she transferred the resident on 4/7/11 because the resident was so tiny. Staff 1 stated that during the transfer the resident became aggressive which caused them both to fall to the floor. Staff 1 stated that she did not know why she didn't look at the resident's care plan. In an interview on 4/27/11 at 2:45 pm Staff 3, RN, stated that on the evening Resident 15 fell she heard the resident yelling in her/his room. Staff 3 looked inside the resident's room and observed Staff 1 in the room and the resident on the floor. Staff 3 stated that Staff 1 told her the resident was lowered to the floor after the resident kicked her. Staff 3 stated that Staff 1 told her the resident had been agitated prior to the transfer. Staff 3 stated that Staff 1 was not using a gait belt during the transfer. 2. Resident 13 was admitted to the facility in 10/2010 with [DIAGNOSES REDACTED]. An admission comprehensive assessment indicated the resident was at risk for falls. The resident's active care plan fall interventions included a bed alarm and fall mat on the floor next to the bed. According to an incident investigation, on 4/13/11 at 3:45 pm, the resident was found on the floor in her/his room. The resident was in a semi-reclined position in front of the night stand. The resident had sustained a laceration to the forehead. The resident had no other injuries. The investigation indicated that the resident's alarm had been in place and was sounding but the fall mat had not been in place on the floor next to the bed. To prevent potential injuries in the future, the resident's bedside table was moved away from the bed and a scoop mattress was placed on the bed. In an interview on 4/25/11 at 12:45 pm Staff 9, RNCM, stated the resident had hit her/his head on the night stand as blood was found on the lower part of the stand. In an interview on 4/25/11 at 11:30 am Staff 4, CNA, stated that on the day the resident fell , she had assisted the resident to bed at approximately 1:45 pm. Staff 4 stated that she had put the resident's alarm in place but forgot to place the fall mat next to the bed.

Based on observation, interview and record review it was determined the facility failed to follow care planned interventions on 2 of 5 sampled resident (#'s 1 and 5) who's care plans were reviewed. As a result, Resident 1 sustained a fracture during a transfer. Finding include: 1. Resident 1 was admitted to the facility in April 2009 with [DIAGNOSES REDACTED]. On 7/15/10 an annual assessment identified the resident understood others but was sometimes understood and had unclear speech. The assessment indicated the resident was totally dependent for care and had range of motion limitations on both sides of the body. The assessment identified the resident was bedfast all or most of the time and was lifted mechanically for transfer. The assessment indicated the resident had mild pain less than daily. The ADL's RAP identified the resident had contractures in all extremities related to her primary [DIAGNOSES REDACTED]. The October 2010 CNA Flow Sheet directed care staff to transfer the resident with two people and a mechanical lift "at all times." On the back of the flow sheet, a CNA (Staff 5) identified that on 10/2/10, in the evening, the resident's arm "popped" during a transfer and had a "small red circle on shoulder blade which was reported to the licensed nurse (Staff 4). There was no Interdisciplinary Progress (IDP) note dated 10/2/10. On the 10/2/10-10/3/10 night shift, a RN (Staff 3) conducted a skin audit and documented no new skin issues onto the October MAR. On 10/3/10, during the day shift, an IDP note identified a large purple bruise measuring 18 cm x 10 cm was found on the resident's upper left arm during patient care while the resident was lying in bed. On 10/4/10, during the night shift, an IDP note indicated the resident had a dark purple bruise on the left arm from the shoulder to the elbow and extending under the arm, back, and left breast. The note identified the resident stated "that her arm was bumped on shower day." The note indicated the bruise was not noted on the 10/3/10 skin audit, appeared during the day on 10/3/10 and increased by the night shift on 10/4/10. On 10/4/10 at 8:05 am an IDP note identified the physician was contacted and ordered an x-ray for the resident. On 10/4/10 at 4:30 pm an IDP note indicated the resident was sent out to the hospital for evaluation. On 10/4/10 an x-ray report identified the resident had a "displaced and comminuted fracture at the junction of the humeral head and neck possible with a separate fracture of the humeral head." On 10/15/10 at 9:32 am Resident 1 was observed to have a faded bruise on her left upper arm. The resident wore an immobilizer on her left arm which attached to her torso. In an interview with her caregiver, Staff 7, CNA, revealed the resident required a mechanical lift for transfer, however, the resident was currently bed bound related to the recent fracture. In an interview on 10/19/10 at 2:30 pm Staff 5, CNA, reported she was assigned to Resident 1 "often" and the resident was care planned to require a mechanical lift for transfer. Staff 5 stated that on 10/2/10, after the resident had returned from a shower, she transferred her without the mechanical lift, hugging the resident's body to place her into bed. Staff 5 reported that during the transfer she heard the resident's shoulder "pop." Staff 5 stated that she asked the resident if she was in pain for which she replied, "yes." However, Staff 5 reported that the resident usually complained of pain around that time of the day, so she had assumed it was a "normal" amount. Staff 5 reported that she verbally reported the incident to the nurse (Staff 4) and documented it on the back of the CNA Flowsheet. In an interview on 10/26/10 at 12:45 pm Staff 6, CNA, reported the resident was care planned to require a mechanical lift for transfer. On 10/2/10, while she assisted Staff 5 with Resident 1, she observed Staff 5 manually transfer the resident and heard the resident's shoulder "pop" when the resident was placed on the bed. 2. Resident 5 was admitted to the facility in December 2009 with [DIAGNOSES REDACTED]. On 8/13/10 the resident's comprehensive care plan identified that he was as risk for fall due to a history of falls, gait disturbance, medications, cognitive impairment, impulse control issues, decreased mobility, and increased behavioral issues. The care plan indicated the facility's interventions included a personal alarm on while the resident was in bed or in the chair. The alarms intervention was not transferred onto the October 2010 CNA Flow Sheet (the care plan CNAs receive direction from). On 10/20/10 at 4:05 a Post Fall Assessment identified the resident was found on the floor, face down with a laceration on his right eyebrow. The assessment indicated the resident was unable to describe the event and was not wearing a personal alarm at the time of the fall. The assessment identified the alarm was not on the resident due to a transcription error when the CNA Flow Sheet was updated without the "alarms checked." The assessment indicated the alarm would not have prevented the fall as the resident had a history of [REDACTED]. In an interview on 10/28/10 at 2:30 pm Staff 5, CNA, reported the resident's CNA care plan had not identified a personal alarm as an intervention. Staff 5 stated that she assumed it had been discontinued. The alarm had been effective, at times in the past, depending on the placement of the alarm and if anyone was close enough to the resident at the time it sounded. In an interview on 10/29/10 at 11:00 am Staff 2, DNS, reported the alarm intervention was listed on the resident's current comprehensive care planned and had been identified on the July, August and September 2019 CNA Flowsheets. However, when the Flowsheet was updated for October 2010, the alarm was missed the CNAs would not know to place the alarm on the resident.