Every finding on record at Matagorda Nursing & Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated.2. The facility failed to ensure dietary staff used hair restraints properly.3. The facility failed to ensure dietary staff wore closed-heel shoes as required by facility policy.4. The facility failed to ensure personal food items were not stored in 1 of 2 kitchen refrigerators.5. The facility failed to ensure clean utensils, dishes, and carry-out containers were stored properly. These failures could place residents at risk for food borne illnesses.Findings included: An observation of the kitchen on 07/07/2026 starting at 9:09 AM revealed the following: Refrigerator #11. 1 open container of sour cream that was not labeled with an open date.2. 1 open container of 1000 Island Dressing with an open date of 04/29/26, was not labeled with a use by date or expiration date.3. 1 open container of Caesar Dressing with an open date of 04/12/26, was not labeled with a use by date or expiration date.4 1 open container of mayonnaise with an open date of 07/03/26, was not labeled with a use by date or expiration date.5. 1 open container of bacon was not sealed and contained a date of 07/02/2026 that was not specified as the opened or use by date.6. 1 bag of chicken was not labeled with any dates.7. 11 packages of hamburger meat were not labeled with any dates. Dry Storage:1. Salt and pepper shakers, filled and empty, were not covered.2. A cardboard box contained attachments for a meat slicer, was not closed/covered.3. The lid of an open bottle of cinnamon spice was not shut.4. The lid of an open bottle of ground cumin was not shut.5. The lid of an open bottle of Italian seasoning was not shut.6. The lid of an open bottle of onion powder was not shut.7. A plastic bag of open bay leaves was not sealed.8. A plastic container, with a lid, contained sugar out of the original package, was not labeled with a use by date or expiration date.9. A plastic container, with a lid, contained flour out of the original package, was not labeled with a use by date or expiration date.10. A plastic container, with a lid, contained powdered milk out of the original package, was not labeled with a use by date or expiration date.11. A tray contained 3 condiment cups of brown substance, was not labeled or dated.12. A plastic container, with a lid, containing lima beans out of the original package, was not labeled with a use by date or expiration date.13. A plastic container, with a lid, contained rice out of the original package, was not labeled with a use by date or expiration date.14. A plastic container, with a lid, containing pinto beans out of the original package, was not labeled with a use by date or expiration date.15. A plastic container, with a lid, contained black-eyed peas out of the original package, was not labeled with a use by date or expiration date.16. A plastic container, with a lid, containing breadcrumbs out of the original package, was not labeled with a use by date or expiration date. An observation of the kitchen on 07/08/2026 starting at 11:15 AM revealed the following:1. A staff member's bottle of electrolyte drink stored in Refrigerator #1.2. [NAME] A wore shoes with open heels. An observation of the kitchen on 07/08/2026 starting at 4:48 PM revealed the following:1. Styrofoam carry-out boxes stored under the steam table were open and not covered.2. Styrofoam bowls stored under the steam table were open and not covered.3. Dietary Staff B wore a hair net that did not cover the front of her hair.4. [NAME] C wore a hair net that did not cover the sides of her hair.5. Dietary Staff D wore a hair net that did not cover the sides and back of her hair.6. A plastic basket contained built-up utensils that were not covered.7. The ice scoop was stored on top of the ice machine, face up, and was not covered. During an interview on 07/08/2026 at 11:15 AM, the Dietary Supervisor said staff were allowed to store personal items in Refrigerator #1 only.During an interview on 07/08/2026 at 11:22 AM, the Dietary Supervisor said she double-checked on the staff food policy and she was wrong. She said staff were not allowed to store any personal items in any of the kitchen refrigerators.During an interview on 07/08/2026 at 5:10 PM, [NAME] C stated she received training on the expectations of wearing a hair net. She said a hair net should cover the ears and all the hair. She said that if hair was not covered completely, hair could get in the food and contaminate it.During an interview on 07/08/2026 at 5:12 PM, Dietary Staff D stated she received training on the expectations of wearing a hair net. She said a hair net should cover all the hair to prevent hair from getting in the food. She said that if hair got in the food, it would be just gross. She said she has trouble keeping all her hair covered, because her glasses push the hair net back.During an interview on 07/09/2026 at 3:46 PM, the Dietary Supervisor said her expectations for labeling were the item name, the date opened, and the use-by date. She said refrigerated items must be used within 6 days or discarded. She said items in the dry storage must be used by the manufacturer's expiration date or 1 year after opening, if it does not have a manufacturer's expiration date. The Dietary Supervisor said they have a problem with the paper sticker labels dissolving so they usually use masking tape and marker but have been out of masking tape. She said the hamburger meat in the refrigerator had a label, but it must have dissolved. She said she has never attended training, other than the Food Handler's Course and Dietary Manager's course. She said all the failures could cause cross-contamination of food items and illness of the residents.Record review of facility's policy titled, Food Storage and Supplies dated 2012, revealed: Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or best by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality has deteriorated.Record Review of the facility's policy titled, Dietary Food Service Personnel Policy and Procedures dated 2012, revealed: Shoes must be low-heeled and rubber or synthetic soled. Canvas shoes, sandals, or open-heeled or open-toe shoes are prohibited. Hair nets or hats covering the hairline are worn at all times. All unused food must be securely covered. All items are to be dated and labeled as to their content. All paper goods and other disposables must be kept covered to prevent contamination'.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 of 8 residents (#48 and #59) reviewed for ADL care. The facility failed to ensure Resident #48's fingernails were trimmed, filed, and cleaned on 07/07/2026. -The facility failed on 07/07/2026 to assist Resident #59 to shave his facial hair. These failures could place residents at risk of loss of dignity, risk of infections, and a decreased quality of life.Findings included: Record review of the Face Sheet revealed Resident #48 was an [AGE] year-old male whose original admission date was 04/07/2025 with a readmission date of 02/26/2026. Record review of the history and physical dated 02/17/2026 revealed Resident #48 had generalized weakness, muscle wasting (loss of muscle mass), colon cancer (cancer of the large intestine), type 2 diabetes mellitus (high blood sugar disorder), hypertension (high blood pressure), hyperlipidemia (high cholesterol), and age-related cognitive decline (decreased thinking ability associated with aging). Record review of the quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 07, indicating moderately impaired cognition. The MDS revealed under section GG for functional abilities, Resident #48 was dependent on staff with multiple activities of daily living, including personal hygiene and grooming, toileting hygiene, showering, and upper and lower body dressing. Record review of Resident #48's care plan revised on 06/01/2026 revealed interventions directing staff to provide routine hygiene and personal care as part of the resident's daily assistance needs. Resident #48's care plan revealed the resident had diabetes and called for staff intervention to educate the resident, his family and other care givers to monitor his nails and ensuring the should be always cut straight across and to never cut corners, to file rough edges with emery board (a small flat nail file made of stiff carboard with a fine abrasive material). The care plan called for staff intervention to check nail length and trim and clean on bath day and as necessary. During an observation and interview on 07/07/2026 at 9:24 a.m. with Resident #48, the resident was observed lying in bed. The resident's fingernails measured approximately 1.5 centimeters in length and had visible accumulations of dark debris beneath multiple fingernails. The fingernails appeared untrimmed and soiled. Resident #48 stated he did not like his fingernails being long because they would collect dirt, and he would accidentally scratch himself when experiencing an itch or while adjusting his clothing or bed linens. Resident #48 stated he had previously asked facility staff to trim his fingernails but could not recall when he had last made the request. During an observation on 07/08/2026 at 10:02 a.m., Resident #48 was asleep in bed. Observation of the resident's hands revealed they were still long and dirty. Resident #48 still had his fingernails at approximately 1.5 centimeters in length, and they still had visible accumulations of dark debris beneath multiple fingernails. Record review of the face sheet dated 07/09/2026 revealed Resident #59 was a [AGE] year-old male with an original admission date of 06/23/2026 and a readmission on [DATE]. Record review of Resident #59's the history and physical dated 06/06/2026 revealed diagnoses including acute posthemorrhagic anemia (blood loss anemia), atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease (long-term lung disease), hypertension (high blood pressure), panlobular emphysema (advanced damage to the air sacs of the lungs), acute respiratory failure with hypoxia (low oxygen levels), thoracic and lumbar vertebral fractures (broken bones in the spine), generalized weakness, chronic pain, and impaired mobility. Record review of Resident #59's admission MDS dated [DATE] revealed Resident #59 had a BIMS score of 6, indicating severe cognitive impairment. The MDS under section GG for functional abilities revealed the resident required substantial to maximal staff assistance with multiple ADLs, including personal hygiene, dressing, bathing, and grooming. Record review of Resident #59's care plan dated 06/30/2026, revealed interventions directing staff to provide assistance with the resident's daily care needs and maintain personal hygiene while addressing his significant medical conditions and functional limitations. The care plan revealed Resident #59 required assistance with bathing, bed mobility, dressing, and toileting. During an observation and interview on 07/07/2026 at 4:00 p.m., Resident #59 was observed with noticeable facial hair and appeared frustrated while discussing his grooming needs. Resident #59 stated he had been asking facility staff to assist him with shaving because he had been clean-shaven throughout his life and did not like allowing his beard to grow. The resident stated he did not understand why staff had not provided him with an explanation as to why they had not assisted him with shaving or why the facility had not provided him with a razor or an electric razor so he could shave himself. During an observation and interview on 07/08/2026 at 3:22 p.m., Resident #59, continued to have noticeable facial hair and stated he remained frustrated because facility staff had still not addressed his repeated requests for assistance with shaving. Resident #59 stated he was waiting for his physician to communicate with the facility to determine whether he could safely be shaved. The resident stated he was disappointed that no one had followed up with him regarding his requests and that he continued waiting for assistance. During an interview on 07/09/2026 at 10:52 a.m., the DON stated residents had the right to request assistance with personal grooming, including shaving. The DON stated CNAs were primarily responsible for providing shaving during routine care; however, any staff member receiving the request was expected to ensure appropriate follow-up. The DON stated that allowing the request to go unanswered was not acceptable because it could cause the resident to feel ignored, frustrated, and lose dignity. During an interview on 07/09/2026 at 10:59 a.m., the Med Aide stated that when a resident requested to be shaved, the request should be communicated promptly to the assigned CNA or nurse. The Med Aide stated failing to relay the request was inappropriate and could leave the resident feeling overlooked and dissatisfied with his care. During an interview on 07/09/2026 at 11:03 a.m., ADON G stated staff were expected to respect residents' grooming preferences and ensure requests were addressed. The ADON stated unresolved requests did not meet the facility's expectations and could negatively affect the resident's emotional well-being by making the resident feel the staff did not pay attention to him or did not care to assist him. During an interview on 07/09/2026 at 11:17 a.m., ADON G stated licensed nurses were responsible for overseeing that residents' care needs, including grooming requests, were completed. ADON G stated unanswered requests could diminish the resident's dignity and self-esteem. During an interview on 07/09/2026 at 11:28 a.m., the Administrator stated the facility expected staff to respond promptly to reasonable requests for personal care. He stated every caregiver shared responsibility for ensuring concerns reached the appropriate staff member. He stated failing to do so could result in the residents feeling ignored or emotionally distressed. During an interview on 07/09/2026 at 11:46 a.m., the CNA F stated shaving was a routine nursing assistant responsibility unless indicated differently by a charge nurse or the DON. CNA F stated if the resident declined or the task could not be completed immediately, staff should notify the nurse and follow up. CNA F stated leaving the request unaddressed was unacceptable because the resident could feel neglected or embarrassed. During an interview on 07/09/2026 at 10:52 a.m., the DON stated routine fingernail care was part of personal hygiene provided during ADLs. The DON stated CNAs were primarily responsible for trimming fingernails when appropriate, while all caregivers were responsible for reporting concerns. The DON stated excessively long fingernails were unacceptable because the resident could scratch himself, break the skin, bleed, and develop an infection. During an interview on 07/09/2026 at 10:59 a.m., the Med Aide stated that overgrown fingernails should be reported to nursing for follow-up. Med Aide stated that unresolved nail care increased the risk of accidental skin injury and infection. The Med Aide stated it was not acceptable to leave Resident #48's fingernails that long because they looked dirty, and there was also a risk of the resident getting sick if he ate food with his hand and they were dirty. During an interview on 07/09/2026 at 11:03 a.m., ADON[TW1.1] G stated residents declining nail care should receive additional education and be offered the service again. The ADON stated that allowing fingernails to remain excessively long was not acceptable and could place the resident at unnecessary risk for skin injury including scratching, which could lead to bleeding and infection. During an interview on 07/09/2026 at 11:17 a.m., ADON G stated nursing assistants were expected to monitor grooming needs during bathing and notify nursing when additional intervention was required. ADON G stated failure to address the concern did not meet acceptable care standards. ADON G stated Resident #48 could potentially scratch himself and it could result in him having skin break which could potentially result on him developing an infection due to having dirty fingernails. During an interview on 07/09/2026 at 11:28 a.m., the Administrator stated the facility expected residents to receive assistance maintaining appropriate hygiene and grooming. He stated that prolonged failure to address overgrown fingernails could contribute to preventable injury and infection. During an interview on 07/09/2026 at 11:46 a.m., CNA F stated fingernails were routinely assessed during showers and personal care. CNA F stated that refusals should be documented and reported. He stated long fingernails increased the likelihood of scratches, bleeding, and infection. Record review of the facility's Nursing Policy and Procedure Manual titled Nail Care not dated, read in part: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails ail occur in the elderly with some frequency. Goals Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions The resident will be free from infection. Procedure Should be performed according to the resident center plan of care. 7. Trim the nails with a clipper, straight across for the toenails and rounded for the fingernails. 8. Smooth the nails with an emery board. 9. Apply hose and shoes or slippers as appropriate. Record review of the facility's Nursing Policy and Procedure Manual titled Shaving, Electric/Safety Razors, not dated, read in part: Shaving of the male resident can be performed with an electric or safety razor depending on the preference and availability of equipment. It is usually done as a part of daily personal hygiene, although every other day is sufficient for some based on the beard growth. It is done to promote cleanliness and a positive body image. Usually, the resident or a staff member performs the procedure, but the nurse can shave the resident if illness or disability prevents independence. Goals 1. The resident will experience cleanliness and comfort. Procedure Should be performed according to the resident centered plan of care. 1. Assemble the necessary equipment: a basin of warm water (115 degrees F.), shaving cream, the safety razor, a towel, a washcloth, and aftershave. 2. Wash your hands and put on gloves. 3. Explain what you are going to do. 4. Place a towel under the resident=s chin. 5. If the resident wears dentures, be sure they are in his mouth. 6. Put the washcloth in warm water, wring it out, and place it on the face to soften the beard. 7. Apply shaving cream to the face. 8. With the fingers of one hand, hold his skin taut. With the other hand shave in the direction the hair grows. Using short, firm strokes, shave under the sideburns, downward over the cheeks, over the chin, and upward on the neck. 9. Rinse the razor often. 10. Wash the remaining shaving cream off his face. 11. Apply aftershave if the residents desires it. 12. Store all articles in the appropriate place. 13. When finished, dispose of the gloves and wash your hands.

Based on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 8 residents (Resident #48) reviewed for foot care. The facility failed to ensure Resident #48's toenails were trimmed, filed, and cleaned on 07/07/2026. This deficient practice could place residents at risk of poor foot hygiene and decline in residents' physicalcondition.Findings included: Record review of the Face Sheet revealed Resident #48 was an [AGE] year-old male whose original admission date was 04/07/2025 with a readmission date of 02/26/2026. Record review of the history and physical dated 02/17/2026 revealed Resident #48 had generalized weakness, muscle wasting (loss of muscle mass), colon cancer (cancer of the large intestine), type 2 diabetes mellitus (high blood sugar disorder), hypertension (high blood pressure), hyperlipidemia (high cholesterol), and age-related cognitive decline (decreased thinking ability associated with aging). Record review of the quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 07, indicating moderately impaired cognition. The MDS revealed under section GG for functional abilities, Resident #48 was dependent on staff with multiple activities of daily living, including personal hygiene and grooming, toileting hygiene, showering, and upper and lower body dressing. Record review of Resident #48's care plan revised on 06/01/2026, revealed interventions directing staff to provide routine hygiene and personal care as part of the resident's daily assistance needs. Resident #48's care plan revealed the resident had diabetes and called for staff intervention to educate the resident, his family and other care givers to monitor his nails and ensuring the should be always cut straight across and to never cut corners, to file rough edges with emery board (a small flat nail file made of stiff carboard with a fine abrasive material). The care plan revealed the facility needed to refer Resident #48 to a podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. The care plan called for staff intervention to check nail length and trim and clean on bath day and as necessary and to report any changes to the nurse and if the resident was diabetic, the nurse needed to provide toenail care. During an observation and interview on 07/08/2026 at 10:15 a.m. with Resident #48 and the DON, the DON assisted the resident with removing his socks for assessment. Observation revealed both feet had excessively long toenails. Several toenails appeared yellow in color, while others were jagged, broken, and irregular in shape. The DON acknowledged the toenails required attention and stated the condition was not an acceptable standard of care. The DON stated diabetic residents with excessively long or damaged toenails should be evaluated for podiatry services and monitored routinely. The DON stated that allowing the toenails to remain in this condition could place the resident at risk for discomfort, skin injury, irritation, bleeding, and infection, particularly because of the resident's diagnosis of diabetes.During an interview on 07/09/2026 at 11:01 a.m., the Med Aide stated abnormal toenails should be reported promptly to nursing. She stated diabetic residents were especially vulnerable to foot injuries and infections and stated it was not acceptable for Resident #48 to have his toenails in that condition. During an interview on 07/09/2026 at 11:05 a.m., ADON G stated follow-up should continue whenever podiatry services were indicated but declined by a resident. She stated ongoing education was necessary to reduce avoidable complications. The ADON stated that Resident #48's toenails were too long and that he could potentially injure himself by scratching and breaking his skin, potentially developing an infection or cause pain if his toenails were caught in his socks. During an interview on 07/09/2026 at 11:19 a.m., ADON G stated nursing staff were responsible for coordinating podiatry referrals and monitoring diabetic foot care. She stated the Resident #48's untreated long toenails could lead to pressure areas, cuts, infection, and delayed healing. During an interview on 07/09/2026 at 11:30 a.m., the Admin. stated residents requiring specialized foot care should be referred without unnecessary delay to a podiatrist. The Admin. stated leaving the concern unresolved was unacceptable because preventable injuries could occur. The Admin. stated that Resident #48's toenails should have been addressed before they got long and started to break. During an interview on 07/09/2026 at 11:48 a.m., CNA F stated foot abnormalities observed during personal care should always be reported to nursing. He stated excessively long toenails could cause cuts, bleeding, pain with walking, and infection. CNA F stated that residents with a diagnosis of diabetes such as Resident #48 needed to be referred to a podiatrist for his toenails to be properly trimmed to avoid injuries. Record review of the facility's Nursing Policy and Procedure Manual titled Nail Care not dated, read in part: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails ail occur in the elderly with some frequency. NAIL CARE, ESPECIALLY TRIMMING, IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERIPHERAL VASCULAR DISEASE.GoalsNail care will be performed regularly and safely. The resident will be free from abnormal nail conditions The resident will be free from infection.ProcedureShould be performed according to the resident center plan of care.7. Trim the nails with a clipper, straight across for the toenails and rounded for the fingernails.8. Smooth the nails with an emery board.9. Apply hose and shoes or slippers as appropriate.12. Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Report conditions immediately to the primary nurse. The nurse will ensure a refe1ral to the podiatrist.13. Cutting should not be any shorter than at the line even with the nail folds on each side.14. When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident # 13) of 8 residents reviewed for infection control. The facility failed on 07/07/2026 to ensure Resident #13's nasal canula was not touching the floor. This failure could place residents at risk of cross contamination resulting in acquired infection or illness.Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident # 13) of 8 residents reviewed for infection control. The facility failed on 07/07/2026 to ensure Resident #13's nasal canula was not touching the floor. This failure could place residents at risk of cross contamination resulting in acquired infection or illness. Findings included: Record review of the Face Sheet dated 07/07/2026 revealed Resident #13 was an [AGE] year-old female admitted to the facility on [DATE]. Record review of the history and physical dated 02/21/2026 revealed Resident #13 had severe COPD (long-term lung disease causing difficulty breathing) with home oxygen dependence requiring 3 liters of oxygen by nasal cannula. The H&P documented oxygen therapy was maintained via nasal cannula throughout hospitalization, with episodes of oxygen desaturation managed by increasing oxygen flow. Additional diagnoses included hypertension (high blood pressure), hypothyroidism (underactive thyroid), rheumatoid arthritis (chronic inflammatory joint disease), postoperative anemia (low red blood cell count after surgery), severe protein-calorie malnutrition (poor nutritional status), and a right intertrochanteric femur fracture (broken upper thigh bone). Record review of Resident #13's significant change in status MDS dated [DATE] revealed the resident had a BIMS score of 5 indicating the resident was severely cognitively impaired. The MDS revealed under section I for active diagnoses that Resident #13 had asthma and (a chronic lung disease that causes airways to become inflamed and narrowed, making it difficult to breathe) COPD. Under section J for health conditions, the MDS revealed the resident had shortness of breath. Under section O the MDS revealed that Resident #13 received therapy services including respiratory therapy for at least fifteen minutes the seven days of the week.Record review of Resident #13's care plan, initiated 03/09/2026 and revised through 05/19/2026, revealed the resident was care planned for emphysema/COPD (long-term lung diseases that make breathing difficult) and oxygen therapy (treatment that provides extra oxygen to help with breathing). Interventions directed staff to administer oxygen therapy as ordered by the physician, maintain oxygen at 2-4 LPM (liters of oxygen delivered per minute) via nasal cannula (small tubes placed in the nostrils to deliver oxygen); monitor for respiratory distress (difficulty breathing), including changes in respirations, pulse oximetry (measurement of blood oxygen level), restlessness, confusion, cyanosis (bluish discoloration of the skin or lips caused by low oxygen), cough, hemoptysis (coughing up blood), accessory muscle use (using extra neck and chest muscles to breathe), and skin color; notify nursing immediately if oxygen was off the resident, position the resident to promote lung expansion and prevent respiratory compromise; monitor for signs of respiratory infection, and ensure oxygen delivery continued appropriately during meals. During an observation and interview on 07/07/2026 at 9:10 a.m. with Resident #13, the resident was observed in bed receiving oxygen via a nasal cannula. The resident was noted to have intermittent coughing and appeared to have trouble breathing during the observation. The nasal cannula was observed extending from the resident's nose to the oxygen concentrator, with a portion of the cannula tubing lying directly on the floor. The floor was visibly soiled with debris, lint, and dust. Resident #13 stated she did not know when her nasal cannula had last been changed by staff. During an interview on 07/08/2026 at 10:38 a.m., the Director of Nursing (DON) stated staff were responsible for ensuring oxygen equipment remained clean and positioned to prevent contamination. The DON stated nasal cannulas should never be allowed to rest on the floor because the floor was considered a contaminated surface. The DON stated this finding was not an acceptable infection control practice and explained that if a contaminated cannula were returned to the resident's nostrils, microorganisms could be introduced into the respiratory tract, increasing the risk for respiratory infection or other illness. During an interview on 07/08/2026 at 11:00 a.m., the Medication Aide stated she routinely observed residents during medication passes, and was expected to report concerns involving oxygen equipment to the licensed nurse. She stated a nasal cannula observed touching the floor should be repositioned or replaced as appropriate and reported immediately. She stated allowing the cannula to remain on the floor was not acceptable because contamination could place the resident at risk for infection when receiving oxygen therapy. During an interview on 07/08/2026 at 11:15 a.m., the Assistant Director of Nursing (ADON) stated licensed nurses were responsible for overseeing oxygen therapy and ensuring tubing and cannulas remained clean. She stated a nasal cannula touching the floor should have been addressed immediately. She explained the practice was inconsistent with infection prevention standards because bacteria or other contaminants from the floor could be transferred into the resident's nose and respiratory system, increasing the potential for infection. During an interview on 07/08/2026 at 11:26 a.m., the Administrator stated the facility expected staff to follow established infection prevention practices while providing resident care. He stated oxygen equipment should be maintained in a clean condition, and should not be allowed to contact the floor. He stated the observation was not acceptable because residents relied on staff to minimize avoidable exposure to contamination that could contribute to illness. During an interview on 07/09/2026 at 11:44 a.m., the Certified Nursing Assistant (CNA) stated all direct care staff shared responsibility for reporting unsafe conditions involving resident care equipment. He stated if a nasal cannula was observed touching the floor, staff should immediately notify the nurse and correct the issue if able. He stated leaving the cannula on the floor could expose the resident to germs and increase the risk of a respiratory infection. During an interview on 07/09/2026 at 10:48 a.m., the Assistant Director of Nursing (ADON) stated routine rounds should include observing oxygen equipment to ensure it remained clean and properly positioned. She stated cannulas should not come into contact with the floor because doing so created an unnecessary infection control concern. She stated the finding did not meet expected nursing practice because contamination of the cannula could expose the resident to harmful microorganisms and potentially result in respiratory illness. Record review of the facility's policy and procedures, revised October 2010, titled, Oxygen Administration, read in part: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 nurse medication carts reviewed for pharmacy services. The treatment nurse failed to ensure her nurse medication cart was secured when it was left unattended. This failure could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation and interview on 07/07/2026 at 9:08 AM, the nurse medication cart was observed in the hallway unlocked and unattended. The cart's lock was noted to be in an outward position, indicating the cart was unlocked. The treatment nurse was in the resident's room with the door closed. The treatment nurse came out of a resident's room and was asked if that was her cart and the nurse answered Yes. The nurse said that she normally locked the cart whenever she stepped away from the cart, but had forgotten to that time. Inside the treatment cart were several medication tubes that contained several different types of creams and ointments. There were also some scissors, disinfectant wipes, and wound cleanser solutions on the rest of the drawers. The treatment nurse said the residents could get into the cart and get into the items which could hurt them. The treatment nurse said it could also give access to other staff that had no business getting into her cart. An observation and interview on 07/08/2026 at 9:22 AM, revealed the nurse medication cart was observed in the hallway unlocked and unattended. The cart's lock was noted to be in an outward position, indicating the cart was unlocked. The treatment nurse was in the resident's room with the door closed. The DON was in the area and was shown that the cart in the hall, was unlocked. The DON said the cart was supposed to be locked when left unattended and locked the cart at that time. The treatment nurse came out of the resident's room and said she had forgotten to lock the cart again. Interview on 07/09/2026 at 4:12 PM, the DON said the nurse medication carts were expected to be locked when unattended. The DON said that possible negative outcomes could be that anybody could have access to the cart, including residents that might get something from the cart. Interview on 07/09/2026 at 4:20 PM, the Administrator said it was expected for the nurses to lock their medication carts when they were away from the cart. The Administrator said if the medication cart was left unlocked and unattended, then there was a possibility of residents opening the drawers and taking some of the medications. Review of the facility's policy titled Medication Storage in the facility and dated March 2025 indicated in part: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts and medication supplies are locked or attended to by persons with authorized access.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #13) of 8 residents observed for oxygen management quality of care. The facility failed on 07/07/2026 to ensure Resident #13's humidification component of oxygen therapy was properly maintained and identified resulting in the resident receiving oxygen through an empty, undated, and unlabeled humidifier bottle while oxygen therapy was being administered. This deficient practice had the potential to expose residents receiving oxygen therapy to inadequate humidification of inspired oxygen, increasing the risk of nasal and airway dryness, irritation, and discomfort. The absence of a date and label had the potential to prevent staff from verifying when the humidifier bottle was last changed, increasing the risk that respiratory equipment would not be maintained in accordance with practices and accepted standards of respiratory care.Findings included: Record review of the Face Sheet dated 07/07/2026 revealed Resident #13 was an [AGE] year-old female admitted to the facility on [DATE]. Record review of the history and physical dated 02/21/2026 revealed Resident #13 had severe COPD (long-term lung disease causing difficulty breathing) with home oxygen dependence requiring 3 liters of oxygen by nasal cannula. The H&P documented oxygen therapy was maintained via nasal cannula throughout hospitalization, with episodes of oxygen desaturation managed by increasing oxygen flow. Additional diagnoses included hypertension (high blood pressure), hypothyroidism (underactive thyroid), rheumatoid arthritis (chronic inflammatory joint disease), postoperative anemia (low red blood cell count after surgery), severe protein-calorie malnutrition (poor nutritional status), and a right intertrochanteric femur fracture (broken upper thigh bone). Record review of Resident #13's significant change in status MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating the resident was severely cognitively impaired. The MDS revealed under section I for active diagnoses that Resident #13 had asthma and (a chronic lung disease that causes airways to become inflamed and narrowed, making it difficult to breathe) COPD. Under section J for health conditions, the MDS revealed the resident had shortness of breath. Under section O the MDS revealed that Resident #13 received therapy services including respiratory therapy for at least fifteen minutes, the seven days of the week. Record review of Resident #13's care plan, initiated 03/09/2026 and revised through 05/19/2026, revealed the resident was care planned for emphysema/COPD (long-term lung diseases that make breathing difficult) and oxygen therapy (treatment that provides extra oxygen to help with breathing). Interventions directed staff to administer oxygen therapy as ordered by the physician, maintain oxygen at 2-4 LPM (liters of oxygen delivered per minute) via nasal cannula (small tubes placed in the nostrils to deliver oxygen); monitor for respiratory distress (difficulty breathing), including changes in respirations, pulse oximetry (measurement of blood oxygen level), restlessness, confusion, cyanosis (bluish discoloration of the skin or lips caused by low oxygen), cough, hemoptysis (coughing up blood), accessory muscle use (using extra neck and chest muscles to breathe), and skin color; notify nursing immediately if oxygen was off the resident, position the resident to promote lung expansion and prevent respiratory compromise; monitor for signs of respiratory infection, and ensure oxygen delivery continued appropriately during meals. During an observation and interview on 07/07/2026 at 9:07 a.m. with Resident #13, the resident was observed in bed wearing a nasal cannula connected to an oxygen concentrator. The oxygen concentrator had a humidifier attached; however, the humidifier reservoir was completely empty. The resident stated she did not know how long the humidifier had been empty. Resident #13 further stated that her nose frequently became dry and irritated while receiving oxygen, and that she would scratch her nostrils and apply cream to help relieve the dryness and irritation. During an interview on 07/08/2026 at 10:36 a.m., the DON stated that residents receiving oxygen, with a humidifier, should have the humidifier reservoir checked routinely to ensure it contained distilled water as ordered. The DON stated nursing staff were responsible for monitoring the equipment and addressing concerns promptly. The DON stated that allowing a humidifier to remain empty was not an acceptable standard of care because it could contribute to dryness and irritation of the resident's nasal passages and reduce comfort during oxygen therapy. The DON stated that prolonged failure to address the issue could place the resident at risk for ongoing irritation and other respiratory discomfort. During an interview on 07/08/2026 at 10:58 a.m., the Med Aide stated she observed residents receiving oxygen during medication pass and would report equipment concerns to the charge nurse or the DON. The Med Aide stated an empty humidifier should be brought to the attention of nursing immediately so it could be refilled or replaced as ordered. The Med Aide stated it was not appropriate for a resident to continue receiving oxygen with an empty humidifier if the issue had been identified because it could result in dryness and irritation to the nose and make oxygen therapy less comfortable. During an interview on 07/08/2026 at 11:13 a.m., the ADON stated licensed nursing staff were responsible for ensuring oxygen equipment remained in proper working order, including verifying the humidifier contained distilled water when prescribed. The ADON stated that an empty humidifier should have been corrected without delay. The ADON stated failure to maintain the humidifier appropriately was not consistent with expected nursing practice and could contribute to nasal irritation, discomfort, and decreased tolerance of oxygen therapy. During an interview on 07/08/2026 at 11:24 a.m., the Administrator stated the facility expected staff to provide care in accordance with physician orders and accepted nursing standards. The Administrator stated concerns involving oxygen equipment should be addressed as soon as they were identified. The Administrator stated allowing a resident's oxygen humidifier to remain empty was unacceptable because residents depended on staff to maintain necessary equipment, and failure to do so could negatively affect the resident's comfort and respiratory status and could potentially lead to skin breakdown, around the nose, and irritation. During an interview on 07/09/2026 at 11:42 a.m., CNA F stated direct care staff were expected to notify the DON immediately whenever oxygen equipment appeared abnormal or when a resident complained of irritation while receiving oxygen. CNA F stated that, although licensed nurses were the main responsible for maintaining the oxygen equipment, all staff shared responsibility for reporting concerns. CNA F stated leaving an empty humidifier unreported could result in the resident experiencing dryness and irritation. During an interview on 07/09/2026 at 10:46 a.m., the ADON G stated residents receiving oxygen should be assessed for comfort and for any signs that oxygen equipment required attention. ADON G stated that an empty humidifier should have been identified and corrected during routine nursing care. ADON G stated the finding was not an acceptable nursing practice because failure to maintain the humidifier could contribute to nasal dryness, irritation, and decreased comfort while receiving oxygen therapy. During an interview on 07/09/2026 at 9:56 a.m., The Administrator stated the facility did not have a policy related to humidifiers used with oxygen concentrators.

Based on record review and interviews, the facility failed to ensure residents or their responsible parties were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment for 1 resident (Resident #1) of 5 residents reviewed for informed consents. The facility failed to ensure Resident #1's responsible party was informed of the risks and benefits prior to anti-psychotic medications being administered. This failure could place the residents at risk of receiving medications with side effects they do not wish.Findings include: Record review of Resident #1's undated admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included delirium (a sudden change in thinking and awareness that can lead to confusion, memory problems, and hallucinations. Record review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS score of 4 which indicated she had severe cognitive impairment. Section D-Mood indicated she has little interest in doing things and felt down. Her Functional Assessment indicated she used a wheelchair and required substantial assistance with her ADLs. Section I-Active Diagnoses did not include any psychiatric/mood disorder. Record review of Resident #1's care plan, dated 4/30/26, revealed she had depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and receives antidepressant medications. Record review of Resident #1's physician orders, dated 6/09/26, for Mirtazapine (antidepressant medication) beginning 6/30/2026 for anxiety, appetite stimulant, and depression. Record review of Resident #1's July 2026 medication Administration record reflected the resident began receivingMirtazapine 15mg every evening on 6/30/26. Record review on Resident #1's revealed no record of consent obtained prior to administering. There was no indication the responsible party had given verbal consent. In an interview on 7/9/26 at 3:15 PM the DON stated nurses are responsible for ensuring consents for antipsychotic medications are signed prior to the medication being administered. She stated she is then responsible for double checking the consents. She stated the risk of the resident receiving antipsychotic medications without being informed of the risks, benefits, and side-effects of the medication could be the resident having unexpected outcomes from the medication. In an interview on 7/9/26 at 4:38 PM Resident #1's responsible party stated they did not recall signing the consent for antipsychotic medications or talking with it over the phone with anyone. They stated there was so much paperwork signed and so many phone calls he may have given consent and not remembered it. He had no concerns about the resident taking the medications because she had taken them before being admitted to the facility. In an interview on 7/9/26 at 4:45PM with the Administrator he stated that it is ultimately the DON's responsibility to monitor the process for psychotropic consents. He stated the risk in not obtaining the consent prior to administration could be unwanted side effects. The administrator stated there have been no negative outcomes due to the deficient practice. A record review of the facilities revised 7/1/2026 titled Psychotropic Medication revealed in part: Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication.

Based on observation and interview, the facility failed to have the most recent survey of the facility posted in a place readily available to resident's, family members and legal representatives. The facility failed to ensure that the previous annual survey results were freely available and visible to the public without having to be requested from staff. This failure could place residents at risk of not being able to exercise their right to be aware of the past history of citations of the facility that they reside in.Findings Include: During an observation on 7/7/2026 at 10:10am, no signs or labels could be located within the halls of the facility that would have indicated where the previous annual survey results would have been located. No binders or folders indicated that it would have contained the records of the results were found. During an interview on 7/08/2026 at 3:00pm, during the Resident Council meeting, the residents were not aware of the existence nor of the location of the previous annual survey results. Resident #1 said that he would have liked to have read them if he had known about them or knew where they had been. During an interview on 7/9/2026 at 3:45pm with the Administrator, the previous annual survey results were requested. The Administrator searched in his office and found a yellow folder containing the 2025 survey results inside of his desk. The Administrator said that the results were freely accessible to the residents and public. He said they were usually out in the hallway. He said the records had been in his office as he had been getting ready to prepare a new binder due to it had almost been a year since the prior annual survey. He said that upon entry of the survey team on 07/07/2026, the previous year's annual survey results were in his office, either in his desk or on the bookshelf. The Administrator said that if survey results were not available it would make the records not freely accessible to the public. The Administrator said that the risk of these results not having been freely available is that the public may not have been aware of the past survey history. During an interview on 07/07/2026 at 5:00pm, the Administrator said he locked his office when he was not present in the building, such as outside of his normal work hours. The Administrator stated they did not have any policies on posting survey results.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents hazards and supervision, in that: CNA A failed to perform an appropriate Hoyer Lift transfer with two staff as required, which resulted in Resident #1 sustaining a fall with head injury on 12/30/2025.Resident #1 was transferred from Local Hospital A to City Hospital B's Neuroscience ICU with a diagnosis of a brain bleed and subdural hematoma with subarachnoid hemorrhaging on 12/30/2025. An IJ was identified on 12/31/25. The IJ template was provided to the facility on [DATE] at 4:20 pm. While the IJ was removed on 1/1/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor the implementation of the plan of removal. The failure could place residents at risk of experiencing accidents, injuries, and/or death. The findings included:Record review of Resident #1's face sheet revealed an eighty-three-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were dementia (Dementia is the loss of cognitive functioning that interferes with daily life and activities), heart failure, and morbid obesity (a BMI of 40 or higher). Record review of Resident #1's care plan revealed that she had an ADL self-care performance deficit. Interventions required the use of a Hoyer lift with 2 people (dated 3/4/25), and she was a 2 staff total assist for all transfers and bed mobility. Record review of Resident #1's weights and vitals dated 12/8/25 revealed that she was 66 inches in height (5'5) and weighed 272.5 lbs. Record review of Resident #1's MDS dated [DATE] (resident assessment tool used to document a resident's clinical status, functional abilities, and care needs), Section C titled Cognitive Patterns, revealed a BIMS (cognitive assessment) score of 15 (cognitively intact). Review of Section GG Functional Abilities, subsection Mobility revealed that Resident #1 was dependent on staff for toilet transfers, tub/shower transfers, chair to bed transfers, sitting to stand, and lying to sitting on side of bed. Resident #1 utilized a wheelchair but could independently wheel 50 feet with two turns. Record review of the facility's in-service trainings from January 2025- December 2025, revealed that a Hoyer lift training was conducted on 1/6/25, 1/22/25, and 12/30/25 (completed after the incident). CNA A's name was not listed on the in-services. Record review of Resident #1's progress notes effective on 12/31/25 at 3:50 a.m., LVN B documented that Resident #1 fell from the Hoyer lift during a transfer in her room at 3:50 a.m. She sustained bleeding to the back of the head and pressure was applied to stop the bleeding. Resident #1 had complaints of continuous pain located on the back or her head, left shoulder, and left heel. She was sent to Local Hospital A by EMS at 4:35 a.m. Nurse practitioner, ADON, and FM were notified. Record review of Resident #1's Neuro Assessment progress note, effective on 12/31/25 at 3:50 a.m., LVN B documented the following:BP- 177/115. P-85.Eyes Opening: Spontaneously.Best Verbal Response: Oriented to person, place and time.Best Motor Response: Obeys Commands; example stick out your tongue, squeeze my hand.Pupils equal and reactive to light: YesRight Pupil (blank=assessment not required):Left Pupil (blank=assessment Record review of the Hoyer lift company service dated 12/9/25 revealed that 3 Hoyer lifts were inspected. Documentation stated that calibrations were performed on the lifts and all lifts were in good calibration and working order. In an interview on 12/30/25 at 11:54 am with the ADM, she stated that Resident #1 was admitted to Local Hospital A with a laceration to the back of her head and she provided the contact numbers for CNA A and LVN B. She stated that CNA A had been suspended that morning pending investigation. In an interview on 12/30/25 at 12:09 p.m., CNA A stated that she was hired in June 2025 and worked the 6 p.m.- 6 a.m. shift. She recalled on 12/30/2025 around 3:30 am, she began to get Resident #1 ready to get out of bed to her wheelchair using the Hoyer lift. She said although Resident #1 was a 2 person assist, she decided to perform the transfer on her own because the other aide was busy. During the transfer, she explained that the Hoyer arms that attached to the sling were wobbling and the sling on the right side slipped off the hook and Resident #1 fell straight down and hit her head. CNA A noted seeing blood on the floor and immediately notified her LVN B. She explained that she did the Hoyer transfer by herself because that's how it is at the nursing home, everybody does it by themselves. I didn't think anything bad would happen. CNA A recalled that Resident #1 was very alert and was able to communicate what was going on. She could not remember when she last received training using the Hoyer lift and stated that she might have gotten one when she was hired. In an interview on 12/30/25 at 12:25 p.m., CNA B stated that she had worked at the facility for 1 year and she worked the 6 a.m.- 6 p.m. shift. She identified that there were 2-3 people on her assigned hallway that required a Hoyer lift for transfers and the transfer should always be completed with 2 people. She stated that before she received the Hoyer lift training on the morning of 12/30/25, the last time she could recall receiving training was 4 months ago. In an interview on 12/30/25 at 12:35 p.m. with CNA C, she stated that she had worked at the facility for 6 months and she worked the 6 a.m.- 6 p.m. shift. She stated that she had 2 people on her assigned hall that required Hoyer lift transfers, and she always performed them with 2 people. She received an in-service on Hoyer lift transfers on 12/30/25 around 11:15 a.m. Prior to this in-service, she recalled the last Hoyer lift training to be in October 2025. In an interview on 12/30/25 at 12:54 p.m. with CNA D, she stated that she was hired in April of 2025 and she worked the 6 a.m. -6 p.m. shift. She stated that she was comfortable doing Hoyer lift transfers and they should always be done with 2 people and never one. Her most recent Hoyer lift transfer in-service was on 12/30/25 around 11 a.m. and her last in-service was sometime in August or September. She denied ever seeing or having knowledge of any staff members performing Hoyer lift transfers without the assistance of one or two additional people. In an observation on 12/30/25 between 1:23 p.m. and 1:35 p.m., two Hoyer lift transfers were observed with CNA B, CNA D, and CNA H. Both transfers were performed with at least 2 aides. In an interview on 12/30/25 at 1:37 p.m. with Resident #2 who resided on Hall C, she stated that she usually left her room for lunch in her wheelchair, but she did not that day. For transfers, she said that staff used the hoyer lift and it was usually done with one person. She could not recall the name of the person who did the hoyer lift transfers by themselves but stated that she called them Ms. [CNA's first name] CNA E. Record review of the facility's schedule provided 12/30/25 for 12/31/25 revealed that there was an aide named (CNA E's first name) CNA E who was assigned to work Hall C. An attempt was made on 12/30/25 at 2:30 p.m. to visit Resident #1 in Local Hospital A. Hospital receptionist (name not captured) stated that there were no residents at that hospital with that name and she could not pull up any admission information. The receptionist called a nurse on the phone and she informed that Resident #1 was air lifted from Local Hospital A to City Hospital B earlier that day. An attempt for records request was made on 12/30/25 at Local Hospital A But was unsuccessful. In an interview on 12/30/25 at 2:56 p.m., the HCO from Local Hospital A stated that she could not provide Resident #1's hospital documentation, but she was willing to offer some information verbally once she confirmed the surveyor's organization. HCO disclosed that Local Hospital A sent Resident #1 out to City Hospital B because she had a level of trauma that the hospital could not handle and she needed to be transferred out for a higher level of care due to a subdural hematoma (a type of bleeding inside your head). In a follow up interview on 12/30/25 at 4 p.m., ADM stated she was informed at 12 noon that Resident #1 had been transported from Local Hospital A to City Hospital B. In an interview on 12/30/25 at 4:05 p.m. with the DON, she stated that she had worked at the facility for 1 year and she worked 8 a.m.- 5 p.m. She stated that she called Local Hospital A around noon and she was informed that she was transferred due to a subdural hematoma. DON recalled that when she reached out to CNA to explain what happened to Resident #1, she was crying so much that she could barely speak. She was suspended that morning pending investigation and was terminated not too long ago that day. DON explained that every night, she scheduled 4 aides and 2 nurses to cover the 5 halls. DON stated that all transfers were to be conducted with 2 staff members. She had no knowledge that staff were transferring residents with one person and stated the harm in not performing Hoyer lift transfers with at least two-person assistance could be injury or hospitalization. In an interview on 12/30/25 at 4:23 p.m. with Resident #1's FM, they stated Resident #1 was currently in City Hospital B and had been moved from the ER to the Neuroscience ICU. He stated that he got a call from the nursing home at 9:30 am and he informed them of her transport from the local hospital. In an interview on 12/30/25 at 4:27 p.m. with the Maintenance Director, he stated that the Hoyer lift company came quarterly to do inspections and calibrations. If the company identified issues, they would inform him, and he would either see if he could fix it or outsource to someone who could. He stated that after the incident that occurred that morning with Resident #1, he was asked to assess the Hoyer lift that was used for any malfunctions. He could not find any issues and he informed that a representative from the Hoyer lift company was in route to the facility today to inspect the Hoyer lift and perform any necessary repairs. He explained that when the Hoyer was delivered, it came in a total of 4 pieces and he attached the base to vertical and horizontal pieces with minimal assembly. The last inspection from the Hoyer lift company was on 12/9/25. In an interview on 12/30/25 at 5 p.m. with LVN B, she stated that she was at the nurse's station around 3:30 a.m. when she heard a loud noise that sounded like metal banging and saw CNA A hurrying down the hallway to inform her Resident #1 had fallen from the Hoyer lift. Upon arrival, Resident #1 was lying on the floor with her head laying on top of the leg of the Hoyer lift and the other leg was bent beneath her body. Resident #1 was in shock and complained of pain to her shoulder and there was a pool of blood around her head. BP was elevated but she was conscious when EMS arrived for transport. In an interview on 12/30/25 at 5:17 p.m. HC Owner stated that he had driven 4 hours to the facility to ensure the Hoyer lift was operating safely. He stated that the hoyer lift should be inspected daily before use, weekly, monthly, and he was responsible for inspecting them quarterly. He stated that he preached to staff that if the machine did not feel right, do not use it. HC owner stated the facility's Hoyer lift did not have any malfunctions and it was safe for continued use. He stated that if someone fell out of the hoyer lift due to one of the wings becoming unbalanced, it was because the person was not centered in the sling prior to the lift. In an interview on 12/30/25 at 5:40 p.m. with HCCS, she was asked to clarify how often the owner's manual for the Hoyer Lift was updated. She stated that the lift was manufactured in November 2022 but the manual was updated annually in November, with the most recent update in November 2025. In an interview at City Hospital B on 12/31/25 at 9:57 a.m. with RN A, he stated Resident #1 was admitted to City Hospital B Neuroscience ICU on 12/30/25 with diagnoses of brain bleeding and a subdural hematoma with subarachnoid hemorrhages (a life-threatening stroke from bleeding into the space between the brain and its protective membranes). He stated she was stable but was having trouble breathing. In an observation and interview on 12/31/25 at 10:02 a.m., Resident #1 laid in the bed inside the Neuroscience ICU at City Hospital B with a nasal canula in her nose and IVs hooked into her arms. She stated that she fell during a Hoyer transfer and she hit her head. She repeated several times that her head hurt and stated that she was trying to put the pieces together, but she was so weak and getting so tired. A record request was submitted to Local Hospital A and City Hospital B on 1/7/26. A follow up was sent on 1/12/25. No information has been provided at this time. Record review of the Manufactures Hoyer lift instructions, manufactured November 2022, updated annually (November 2025) reflected that at least two people should operate the Hoyer lift during transfer. The Administrator was notified of the IJ on 12/31/25 at 4:20 p.m. and given the IJ template due to the above failures and a POR was requested. On 12/31/25 at 7:36 p.m., the POR was accepted. It was documented as follows: 12/31/2025F689 Free of accident hazards/supervision/devicesPlan of Removal: The facility failed to perform an appropriate Hoyer Lift transfer with two staff as required and resulted in Resident #1 sustaining a fall with head injury on 12/30/2025.Interventions: Resident #1 was transferred to the ER for observation on 12/30/2025.All residents requiring hoyers care plans were reviewed for accuracy of transfer assistance by DON/Designee on 12/30/2025.All nursing staff in serviced on mechanical lift transfers by DON/ADON/Designee on 12/30/2025 and 12/31/2025. DON/ADON/Designee complete the training for all nursing staff for mechanical lift transfers.Employee suspended pending investigation, terminated 12/30/2025.Hoyer was taken out of commission as a precaution until third party came to assess the integrity of the hoyers. Hoyers assessed 12/30/25. No findings were identified.All hoyers were assessed by third party on 12/30/25. No findings were identified.All slings were assessed on 12/30/25 by DON/ADON/Designee. No findings were identified.Signage applied to hoyers stating Must use 2 trained staff1:1 in service with the aide who completed the transfer with insufficient staff on Resident #2, in service was completed by the DON.The Medical Director was notified of the Immediate Jeopardy on 12/31/2025 by the [NAME] ADHOC QAPI meeting was completed by the interdisciplinary team to include the Medical Director 12/30/2025.Live demonstration with staff participation during the hoyer lift in-service on 12/30/2025 and 12/31/2025. Staff not present were in-serviced via phone, and will complete live demonstrations upon return to work. The DON and ADON were in-serviced 1:1 by the ADO, Compliance Nurse on following in-services on 12/31/2025.Abuse and Neglect: The administrator is the abuse coordinator. All allegations of abuse and neglect should be reported to the administrator immediately. If you can't get ahold of the administrator, call the DON.POC Kardex: The Kardex on Point of Care is where you find the amount of assistance required to assist a resident with care.Hoyer Transfers: All residents who require the hoyer for transfers must be completed by two trained staff members. No exceptions. This is for the safety of residents and staff. Hoyer slings are to be replaced every 6 months. If a hoyer sling is frayed it must be removed from use and turned in to your supervisor. If a hoyer or any piece of equipment is malfunctioning the equipment must be removed from use by the staff member and the Administrator must be notified immediately.Falls: If you witness a resident fall or find them on the floor, notify the charge nurse immediately. If you can't find a charge nurse, call the DON or ADON immediately. You can prevent falls by making sure a resident has their walker/ wheelchair, proper footwear, answering the call light timely, frequent toileting, and ensuring the room is free of trip hazards.The Administrator was in-serviced 1:1 by the ADO, Compliance Nurse on following in-services on 12/31/2025.Abuse and Neglect: The administrator is the abuse coordinator. All allegations of abuse and neglect should be reported to the administrator immediately. If you can't get ahold of the administrator, call the DON.POC Kardex: The Kardex on Point of Care is where you find the amount of assistance required to assist a resident with care.Hoyer Transfers: All residents who require the hoyer for transfers must be completed by two trained staff members. No exceptions. This is for the safety of residents and staff. Hoyer slings are to be replaced every 6 months. If a hoyer or any piece of equipment is malfunctioning the equipment must be removed from use by the staff member and the Administrator must be notified immediately. In-services: The following in-services were initiated on 12/30/2025 for all staff members by the DON, ADON, Designee via phone and/or in person. All staff not in-serviced will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignmentAbuse and Neglect: The administrator is the abuse coordinator. All allegations of abuse and neglect should be reported to the administrator immediately. If you can't get ahold of the administrator, call the DON.POC Kardex: The Kardex on Point of Care is where you find the amount of assistance required to assist a resident with care.Hoyer Transfers: All residents who require the hoyer for transfers must be completed by two trained staff members. No exceptions. This is for the safety of residents and staff. Ensuring the residents are centered and the equipment is close by such as the wheelchair close to the bed. Hoyer slings are to be replaced every 6 months. If a hoyer sling is frayed it must be removed from use and turned into your supervisor. If a hoyer or any piece of equipment is malfunctioning the equipment must be removed from use by the staff member and the Administrator must be notified immediately.Falls: If you witness a resident fall or find them on the floor, notify the charge nurse immediately. If you can't find a charge nurse, call the DON or ADON immediately. You can prevent falls by making sure a resident has their walker/ wheelchair, proper footwear, answering the call light timely, frequent toileting, and ensuring the room is free of trip hazards.Monitoring/Verification of Plan of removal The POR was reviewed as follows. The facility created a binder and numbered each tab in the binder with the completed documentation necessary to fulfill the plan. Day 1: Thursday 1/1/26Resident #1 remained at City Hospital B on 1/1/26.A list of 11 residents who required Hoyer lift transfers was provided to the surveyor. Care plans were reviewed for accuracy. Care plans were accurate.Record review of an in-service dated 12/31/25 that covered Abuse and Neglect, POC Kardex, Hoyer Transfers, and Falls revealed that ADON, DON, and ADM were in-serviced. Record review of CNA A's termination documentation revealed that she was terminated on 12/30/25.Record review of an in-service form dated 12/31/25 revealed that CNA E received an one on one education regarding using a Hoyer lift with 2 people and if another staff member was not present, they should reach out to the charge nurse for assistance. Failure to do so could lead to falls, injury, and termination.Record review of QAPI ADHOC, titled Insufficient staff to perform a task/ADL noted the concern that an aid transferred a resident without sufficient staff. Interventions included in-servicing or all direct care staff (nurses, aides, and med aides), audits of hoyers, audits of slings, and audits of the Kardex. Contributors of the QAPI were ADM, ADON, DON, MD, social services, dietary, and activity director.Record review of the Hoyer lift company service dated 12/9/25 revealed that 3 Hoyer lifts were inspected. Documentation stated that calibrations were performed on the lifts and all lifts were in good calibration and working order.Record review of an in-service on 12/30/25 titled How to use a Kardex was conducted with all CNA's and nurses.Record review of an in-service on 12/30/25 titled Notifying appropriate people when equipment is defective. This in-service documented on ensuring the Hoyer sling was properly placed when completing transfers, what to do if the equipment was defective, who to inform regarding defective equipment, and how to use the QR code to notify maintenance. All nursing staff were in-serviced.Record review of an in-service on 12/30/25 titled Falls detailed what to do if you found a resident on the floor and notifying the DON and ADON immediately. All nursing staff were in-serviced.Record review of an in-service on 12/30/25 titled Abuse and Neglect reflected all nursing staff were in-serviced.On 12/30/25, HC Owner traveled to inspect the facility hoyer lifts. No issues were noted. Signage was observed and placed on all Hoyer lifts that stated must use 2 trained staff. CNA E and CNA F were observed on 1/1/26 at 3:02 p.m. performing a Hoyer lift transfer. Hoyer lift was positioned close to the bed and the wheelchair was locked during transfer. Resident was calm without distress. No issues were noted and transfer performed as detailed in facility's POR. MD was interviewed on 1/1/26 at 3:22 p.m. He agreed with the QAPI and stated that they covered which staff should be in-serviced for Hoyer lift transfers, CNAs following the Kardex, discussed if there were any staffing issues and made sure there was enough staff on shift to tend to the needs of the residents. The DON and ADON were to monitor incidents, events, ADLs, admissions, changes in conditions, and any resident declines. CNA E was interviewed on 1/1/26 at 1:11 p.m She stated that she worked at the facility for over 12 years and she worked the 6 a.m.- 6 p.m. shift. She stated that she was not doing hoyer lift transfers without the assistance of a second staff member. The surveyor informed her that she was named by Resident #2 to be conducting hoyer transfers by herself and she stated that the issue had been corrected, and she was in-serviced earlier that day. She stated that all hoyer transfers should be performed with at least 2 staff members. Interviews were conducted on 1/1/26 from 12:54 p.m. to 2:49 p.m. with CNA C, E, F, G, H, I, J, K, L, M, N, O, P, Q, R from the 6 a.m. -6 p.m. and the 6 p.m.- 6 a.m. shift. All staff stated that they were in-serviced on hoyer lift transfers and they completed a return demonstration on performing a hoyer transfer. All aides expressed that they were comfortable using the Hoyer lift and they were only to operate it if there were at least 2 staff members present and to have the resident centered inside the sling. They expressed that if they assumed a hoyer lift machine was defective, they should not operate it, move it from the floor, and let maintenance know as soon as possible by verbal communication and by using the QR code placed on each hall that allowed staff to place direct maintenance requests. CNAs stated that the abuse and neglect coordinator was the ADM and stated that they should alert her immediately if there were any allegations of abuse and neglect. If a CNA was to witness a fall, they were to not touch the resident and inform their charge nurse immediately, followed by the DON/ADON if the nurse was not available. The aides also explained that the Kardex was used to locate the residents' care plan and see what type of care was needed for each resident. Interviews were conducted on 1/1/26 from 1:53 p.m. to 3:56 p.m. with LVN C, D, E, F, and WCN from the 6 a.m. -6 p.m. and the 6 p.m.- 6 a.m. shift. All nurses stated that they were in-serviced on hoyer lift transfers and they completed a return demonstration on performing a Hoyer transfer. All nurses said they were comfortable using the Hoyer lift and they were only to operate it if there were at least 2 staff members present. They expressed that if they assumed a hoyer lift machine was defective, they should not operate it, move it from the floor, and let maintenance know as soon as possible by verbal communication and by using the QR code placed on each hall that allowed staff to place direct maintenance orders. The nurses stated that the abuse and neglect coordinator was the ADM and stated that they should alert her immediately if there were any allegations of abuse and neglect. If a CNA was to witness a fall, Nurses expected them to not touch the residents and inform their nurse immediately. The DON and ADON were interviewed on 1/1/26 from 3:47 p.m. - 3:52 p.m. regarding the in-service topics of 2-person hoyer transfer, abuse and neglect, fall policy, using the QR code for maintenance requests, and removing all defective equipment from the floor. They stated that all care plans were reviewed and accurate. The administrator was notified that the IJ was removed on 1/1/26 at 4 p.m., however the facility remained out of compliance at a scope of isolated and a level of no actual harm due to the facility's need to monitor the implementation of the plan of removal.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure the kitchen's ice machine's internal components were cleaned and sanitized, and free from mold, mildew, and soiling. This failure placed residents at risk of food contamination and foodborne illness. Findings included: Observation of the exterior of the kitchen ice machine on May 27, 2025, at 9:14 AM, revealed a printed event log adhered to the outside of the ice machine. The event title on the form read Ice Machine. The form contained a table in which kitchen staff log events related to the ice machine. The form listed one event, logged by DM, dated 2/3/25, which stated, Cleaned ice machine. Observation of the kitchen's ice machine on May 27, 2025, at 9:15 AM, revealed the presence of black dots with fuzzy, raised appearance, known to be mold, within and in the internal components of the ice machine. Review of the kitchen's daily, weekly, and monthly cleaning schedules on May 27, 2025, at 9:21 AM, revealed the ice machine was to be sanitized monthly, with the last (and only cleaning of 2025) logged on Feb. 2025. In an interview on May 27, 2025, at 9:26 AM, DM stated that she has been employed with the facility for over 10 years, but she has been in her current position for the last 2 years. In an interview on May 27, 2025, at 11:53 AM, DC stated that cleaning logs were to be completed when the cleaning occurred. DC acknowledged that the logs indicated that the ice machine has not been cleaned recently and not monthly. DC said the staff may have forgotten to write down the dates the ice machine was cleaned. In an interview and observation conducted on May 27, 2025, at 11:55 AM, DM stated that their ice machine had just been cleaned. The ice machine cleaning log showed the machine had not been cleaned since Feb. 2025. When this was pointed out to DM, DM she said staff forget to log the cleaning of the machine. DM was shown the black, fuzzy raised dots, known to be mold, under the lid of the ice machine. No contamination of the ice in the machine was observed. DM agreed to clean the ice machine and sanitize its components immediately and update the cleaning log. Review of the of the kitchen's updated daily, weekly and monthly cleaning schedules and logs on May 29, 2025, at 1:10 PM, revealed the ice machine had been cleaned and sanitized by DM on 5/27/25. Observation of the kitchen's ice machine on May 29, 2025, at 1:10 PM, revealed the ice machine and its components had been effectively cleaned and sanitized and the concerning areas of black, fuzzy raised dots, known to be mold mold, were no longer present. In an interview on May 29, 2025, at 1:10 PM, DM stated that all kitchen staff were in-serviced and re-educated on the kitchen's mandatory daily, weekly, and monthly cleaning schedules. DM stated that the schedules, logs, and procedures were printed and posted within the kitchen where they can be easily seen and completed. DM said she will oversee the completion of the required cleaning and designate the tasks to kitchen staff. She will also assist in cleaning. DM stated the importance of doing so is to keep the environment and equipment sanitary for the health and benefit of the residents, staff, and visitors. Review of the facility's In-Service Training Attendance Roster regarding the topic Cleaning Schedules conducted on May 27, 2025, revealed all kitchen staff attended. In an interview on May 29, 2025, at 1:12 PM, DM confirmed she was provided with an in-service and education regarding the cleaning schedules of the kitchen. DM said it is important that surfaces and equipment be cleaned to make sure the kitchen is sanitary and that no harm comes to the residents. DM said it is everyone's responsibility to clean. In an interview on May 29, 2025, at 1:13 PM, DC confirmed she was provided with an in-service and education regarding the cleaning schedules of the kitchen. DC stated the sanitation and cleaning of the kitchen and equipment is necessary in order to ensure residents don't get sick. In an interview on May 29, 2025, at 1:15PM, ADM stated that it is his expectation that the DM will oversee the daily, weekly, and monthly cleaning schedules. ADM said he expects that DM will assign these tasks or complete them herself. ADM stated that he plans to conduct audits to ensure the cleaning schedules are maintained. He said this is important because a clean and sanitary environment prevents residents, staff, visitors and others from getting sick. Review of the facility's Dietary Services Policy & Procedure Manual 2012, Cleaning Schedules policy revealed the following: The dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Procedure: 1. It is the responsibility of the Dietary Service Manager to prepare the daily, weekly, and monthly cleaning schedules. 2. Cleaning schedules are posted at the beginning of each month in the kitchen. 3. It is the responsibility of all employees to follow the cleaning schedule, and to initial by their assignments when completed. 4. See cleaning schedule forms in the appendix. 5. Cleaning schedules are to be individualized to the facility, and it is the responsibility of the DSM to ensure that the assigned tasks are completed when assigned, and in a thorough manner. The cleaning schedules should be updated routinely to include areas that are notes dto need additional cleaning by the white glove inspection checklist, the RD sanitation check, DSM or administrator walk-through inspections, as well as the CMS kitchen observation audit form that is performed monthly by the dietary manager.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #13) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #13. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (bipolar disorder with an onset date of 02/25/25) was present upon Resident #13's admission date on 02/26/25. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #13's face sheet, dated 05/28/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks), anxiety (intense, excessive, and persistent worry and fear about everyday situations), dysphagia (difficulty in swallowing), chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period). Resident #13's face sheet reflected Resident #13's diagnosis of Bi-Polar had an on-set date of 02/25/2025. Record review of Resident #13's quarterly MDS assessment, dated 03/09/25, reflected she had a BIMS score of 00, which indicated resident's cognition was severely impaired. Resident #13 also took an antianxiety medication during the assessment window. The MDS assessment reflected Resident #13 was dependent on staff for toileting and bathing and required substantial/maximal assistance with personal hygiene. Record review of Resident #13's PASARR Level 1 Screening, dated 02/25/25, reflected that Section C Mental Illness was marked as no, which indicated Resident #13 did not have a mental illness. Record review of Resident #13's care plan dated 03/07/25 reflected Resident #13 had a mood problem r/t to diagnosis of bipolar and anxiety disorder. Goal: Resident will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness through the review date. Interventions included Monitor/record/report to MD prn mood patterns s/sx of depression, anxiety, sad mood as per facility behavior monitoring protocols. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. In an interview on 05/29/25 at 11:28 AM, Resident #13 shook her head yes when asked if staff treated her good and took good care of her. She stated she had not really needed to use her call light and she could get up on her own when she wanted to. She stated the staff checked on her frequently and she had no concerns. In an interview on 05/28/25 at 01:58 PM, the MDS nurse stated Resident # 13's PASARR came from the hospital, and it should have been corrected due to it being incorrect. She stated she would have asked for the hospital to correct a PASARR if she received it, and it was wrong, but Resident #13's PASARR had not been corrected. She stated she did not know if anyone at the facility requested that the hospital correct the PASARR. She stated she just started working in the facility 2 weeks ago and she was not aware of the incorrect PASARR. She stated there should have been a form 1012 done for the PASARR to be corrected. She stated she has been trained on completing PASARRs accurately and ensuring the completed PASARRs were completed correctly. She stated if a PASARR was not completed correctly the facility could be fined by the state and the resident could have not received the services that could have possibly been provided to them. In an interview on 05/29/25 at 10:06 AM, the DON stated the MDS nurse was responsible for ensuring the accuracy of PASARRs. She stated the MDS nurse had been trained on checking for the accuracy of PASARRs and the MDS nurse had previously worked for the facility and left for about a month and came back. She stated the MDS nurse should have been checking the PASARRs and making sure they were completed correctly. She stated if the PASARR was not completed correctly, the MDS nurse should have made sure the PASARRs were corrected. She stated if a PASARR was not completed correctly, it could affect the resident by them not being able to receive services that could have been provided to them. In an interview on 05/29/25 at 10:24 AM, the ADM stated the MDS nurse was responsible for the ensuring the PASARRs were completed correctly. He stated he was not sure if the MDS nurse had received training on ensuring the PASSARs were completed correctly but that she had worked there before and left for a while to work at a sister facility and had just recently returned. He stated the MDS nurse should have been checking the PASARRs for accuracy. He stated if a PASARR was completed incorrectly the MDS nurse would have needed to have the PASARR corrected, and it could have affected any services the residents could have possibly received. Record review of the facility's policy, PASRR Nursing Facility Specialized Services Policy and Procedure revised 03/06/19 reflected: Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Three dented cans were on the can rack located in the dry storage room. This deficient practice could place 49 residents who received meals from the main kitchen at risk for food borne illness. Findings included: Observation on 4/16/24 at 8:45 am of the dry storage room revealed the following: -One 108 oz can of yams with a small dent in the middle of the can -One 66.5 oz can of tuna with a large dent at the top of the seam -One 104 oz can of fruit cocktail with a small dent at the top of the seam Interview with the Dietary Manager on 4/16/24 at 8:48 am confirmed the dented cans should have been stored away from the dry storage with the other dented cans. Interview with the Dietary Manager on 4/17/24 at 1:40 pm she said she conducted an in-service with the dietary staff on dented cans. She said the risk to the resident would be exposure to botulism. She said the dietary staff should check for dented cans when the groceries were received on Thursdays, and she went behind staff and checked the cans. Interview on 4/17/24 at 2:07 pm with Dietary Aide A, she said she had worked for the facility for over a year. She said she was in-serviced on dented cans and the in-service was conducted by the Dietary Manager. She said the dented cans in the pantry were overlooked. She said the risk to the resident could cause botulism. Interview on 4/17/24 at 2:09 pm with Dietary Aide B, she had worked at the facility for [AGE] years. She said the in-service was on dented cans. She said dietary staff were not supposed to use dented cans because the resident could get botulism. Interview on 4/17/24 at 2:11 PM with Dietary Cook, she had worked at the facility for 4 months. She said the in-service was on dented cans. She said the dented cans had to be stored away from the dry storage. She said the Dietary Manager is supposed to double check the cans. She said the risk to the resident could expose them to botulism. Record review of the Dietary Services Policy & Procedure Manual dated 2012 under section Food Safety read in part . dented or otherwise damaged cans will not be used unless inspected by the dietary service manager and found not to be dented on the top or seam, and not perforated . dented cans will be stored in a separate location and returned to the food vendor for credit .

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 30 residents reviewed for pharmaceutical services The facility failed to administer Resident (#2) scheduled medication (Prednisone 40 mg ) with the correct dosage according to physician orders. This failure could affect the resident by not receiving a therapeutic dose and could prevent the resident from receiving the highest possible benefit from their medication. Findings included: Record review of [AGE] year-old male resident with history of hemiplegia (paralysis that affects only one side of your body) of right side, altered mental status (comprises a group of clinical symptoms rather than a specific diagnosis, and includes cognitive disorders, attention disorders, arousal disorders, and decreased level of consciousness), and traumatic brain injury (an injury that affects how the brain works) with recent diagnosis of Pneumonia (an infection that inflames the air sacs in one or both lungs) on 04/13/24. His most recent MDS 03/01/24 revealed BIMS summary score of a 0 (severe impairment), and he was non-interviewable. Record review of Physician Orders on 04/17/24, revealed: Prednisone give 20 milligrams (2 tabs =40mg) by mouth one time a day for Pneumonia for 5 Days. The eMAR read to administer Prednisone 40mg by mouth one time a day for 5 Days. Give 2 tabs (40mg) tab. After the state surveyor interview with the MA, the order was changed to Prednisone oral tab 20mg: Give 1 tablet by mouth two times a day related to Pneumonia. Observation and interview on 04/17/24 at 2:37 p.m. with MA A revealed only (1) Prednisone 20 mg tablet missing from the blister pack while doing medication cart check. The instructions on blister pack read to administer Prednisone (2) 20 mg tablets by mouth one time a day. MA A said, she should have administered both prednisone 20 mg tablets to equal a total of Prednisone 40 mg, instead of just (1) 20 mg tab. She said, the risk of not getting his full dosage is that it was not meeting the requirements that was ordered by the physician. In an interview on 04/18/24 at 10:50 a.m., the DON said, MA A didn't fully read the entire order and only administered (1) Prednisone 20mg tab. She said, we spoke with the physician yesterday, and the order was changed to Prednisone 20 mg BID. The risk of not receiving their full medication dosage was that the medication would not be effective. The DON said, the staff was in-serviced annually and during onboarding on medication administration. The State Surveyor asked if MA B had competencies and a skilled checklist on medication administration. However, the DON stated she was unable to find the employees onboarding competencies and/or medication checklist. Record review of the facility's Medication Administration Procedures policy (revised 10/25/17) read in part, . (14. A specific order must be obtained from the Physician to change the dosage form of a resident's medication. 15. Medication errors and adverse drug reactions are immediately reported to the resident's physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. 20. The 10 rights of medication should always be adhered to 1. Right patient, 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation .

Based on observation, interview and record review, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: -The oil in the deep fat fryer was black. -Dented cans were stored with undented cans. -Foods that are open and not sealed/dated. -Equipment was not cleaned. -There were flies in the Kitchen. These failures could place the residents who ate from the kitchen at risk of risk serious complications from foodborne illness as a result of their compromised health status. Findings Included: Observation of the kitchen on 02/28/23 between 09:15 AM - 10:00 AM revealed the following: 1. In the walk-in-freezer was an open box with sausage patties in an open box not sealed. 2. In the Dry storage room were dented cans of applesauce and Mexican chili beans stored with undented cans. 3. The sliver looking metal racks in the ovens were black. 4. The deep fryer in the kitchen had dirty black looking grease with brown or dark gray substance around it. 5. The baseboard next to the walk-in-cooler and the baseboard at entrance to the dining room from the kitchen at the service area was off the wall. Interview and Observation with the Dietary Manager on 2/28/2023 at 10:00 am, she said the deep fat fryer was scheduled to be cleaned on Thursdays. She than said she was going to get the fryer cleaned in the afternoon. She said at that point, she sealed the sausage patties and discarded the dented cans. She said the Dry storage room should be checked daily to ensure dented cans were not stored with undented cans. She said that the repairs were brought to maintenance, and they were waiting for approval from cooperate. Observation of lunch service on 03/01/2023 at 12:30PM, revealed flies to the back of the kitchen near the dry storage room. Interview on 3/2/2023 at 12:40PM with the Dietary Manager, she said the flies must have gotten in the kitchen by the staff leaving the back door open. She said the pest control company usually comes to the facility monthly and as needed to treat insects. She said there was fly trap at the door but was removed when the new company took over. She said she was going to call the pest control company to come and treat the flies and ensure the back door was always closed. Record review of the Dietary Services Policies & Procedure Manual dated 2012 read in part . Food Safety: .We will ensure all food purchase shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal and local laws, and regulations. Food shall be handled in a safe manner . 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly . 7. Dented or otherwise damaged cans will not be used, unless inspected by the dietary service manager and found not to be dented on the top or seam, and not perforated. Dented cans will be stored in a separate location and return to the vendor for credit .

Based on observation, interview, and record review the facility failed to have assessments that accurately reflect the status of 1one of 15 residents (Resident # 29) reviewed for resident assessments in that:. -Resident #29's Significant Change MDS did not accurately reflect her bowel and bladder incontinent. This failure could affect residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings included: Resident #29 Record review of Resident #29's face-sheet revealed a [AGE] year-old female, who was admitted to facility on 01/15/2018 and readmitted [DATE]. Her diagnoses included sepsis (infection), pneumonia (infection that affect the lungs), overactive bladder (frequent or sudden urge to urinate), anemia (lack of healthy red blood cells), bilateral primary osteoarthritis, hypertensive heart disease, anemia pulmonary hypertension(high blood pressure), hyperlipidemia (high levels of fat in the blood), edema, cerebrovascular disease (a condition that affect blood flow to the brain), atrophy of vulva (a condition where the lining of the vagina gets drier and thinner), atrial fibrillation (irregular or rapid heartbeat), gastro-esophageal reflux disease (heart burn)and peripheral vascular disease (is a slow and progressive circulation disorder). Record review of Resident #29's Significant Change MDS dated [DATE] revealed a BIMS score of 15, indicating that the resident was cognitively independent for decision making. Further record review of the MDS revealed the Resident #29 was coded of Functional Status: Activities of Daily Living (ADL) Assistance: For Bed Mobility she was coded as Extensive Assistance with one-person physical assist. For transfer, walk in room, corridor, locomotion on and off the unit she was coded as Supervision with set up help only. For dressing, toilet use, personal hygiene and bathing she was coded as extensive assistance with one-person physical assist. For Bladder and Bowel incontinent Resident #29 was coded as: Occasionally incontinent of bladder and always incontinent of bowel. Record review of Resident #29's Care Plan revised 4/26/2022 revealed Resident continent of both bowel and bladder during waking hours and sleeping hours incontinent of bladder and at times bowel. The goal was to ensure the Resident #29 maintain current continent status. Observation on 03/01/2023 at 9:00 AM revealed Resident #29 was in her room brushing her hair at the sink. She was clean and well-groomed, and no offensive odor detected. She was alert and oriented and could make her needs known. Observation and Interview on 03/01/2023 at 2:20 PM, revealed Resident #29 was observed in bed. She was alert and oriented. Interview at that time Resident #29 said she was able to go to the bathroom by herself. She said she wore a brief because sometimes she dribbles but she does not go in her brief. She said she goes to the bathroom when she needs to defecate (bowel movement). She said a couple weeks ago she was really sick and was in the hospital and when she got back, she was incontinent for about two days and after that she was going to the bathroom by herself. She said she does not go on herself. Interview on 3/1/2023 at 2:30 PM with the MDS Coordinator, she said Resident #29 was not always incontinent of Bowel. She said the resident goes to the bathroom. At that time, she looked at the MDS and said that the coding was incorrect, and she was going to correct the MDS. Record review of Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy read in part . Purpose/Policy . The purpose of the MDS policy is to ensure each Resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental and psychosocial well-being . Federal regulations at 42 CFR 483.20 require that: 1. The assessment accurately reflects the resident status . , 16352

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 5%, based on 6 errors out of 54 opportunities, which involved 3 of 8 residents (Resident's #2, and #33) and 1 of 2 staff (MA A) and ADON, LVN ) observed during medication administration reviewed for medication error, in that: -MA A did not to administer Eliquis tab (apixaban= is a direct -acting oral anticoagulant used to prevent and treat certain types of blood clots), to Resident #33 as prescribed by the physician. -ADON, LVN did not administer Acetaminophen (medication used for pain) and Docusate liquid (medication used for constipation) to Resident #2 as ordered by the physician. These failures could place residents at risk for not receiving adequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #33 Record review of Resident #33's face sheet revealed a [AGE] year old male admitted to facility on 1/20/2020 and re admitted on [DATE]. His diagnoses included multiple sclerosis (a condition that affects your brain and spinal cord) acute embolism and thrombosis (blood clot) of deep veins of right upper extremity, hyperlipidemia (high lipid/fat), dysthymic disorder, acute kidney failure, and elevation of levels of liver transaminase levels (high liver enzymes). Record review of Resident #33's quarterly MDS dated [DATE] revealed his BIMS was 10 out of 15 indicating he was moderately impaired. Record review of Resident #33's Physician order summary report on 02/28/23 had Active Orders as of: 09/19/2020 read in part .Eliquis Tablet 5 MG (Apixaban)Give 1 tablet by mouth two times a day related to ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF RIGHT UPPER EXTREMITY. Do not crush . Record review of Resident #33's MAR on 02/28/23 at 8:00 AM and dates 02/1/2023-02/28/2023 revealed the Eliquis tablet 5 mg (apixaban) give 1 tablet by mouth. two times daily. Do not crush was scheduled for administration at 8:00 AM and 5:00 PM. Observation of medication administration on 2/28/23 at 5: 32 PM revealed, MA A picked up blister packet punched Eliquis tab 5 mg 1 tablet and other medications, crushed it, then put it in chocolate pudding before administering by mouth to Resident #33 (Resident #33's blister pack for Eliquis had Do not crush). Interview with MA A on 2/28/23 at 6:00 PM regarding Resident #33's Eliquis, medication administration, she said Resident liked his medication crushed. Interview with Resident #33 on 3/1/23 regarding medications being crushed stated, the staff always crush my medication, I do not have a problem swallowing. Interview via telephone with MA A on 3/2/23 at 10:17 AM, she said she had been the medication aide for the facility for 3 years and she had training then. MA A said she did not have recent training and she knew to check Resident medication and blister packet and compare it with the computer. She said she was not aware that Eliquis should not be crushed. She said she would be very careful. Resident #2 Record review of Resident # 2's admission record revealed he was a [AGE] year-old male who was admitted [DATE] and was readmitted on [DATE]. His diagnoses included other sequelae of other cerebrovascular disease (Stroke), sepsis, urinary tract infection, gastrostomy, major depressive disorder, single episode, dysphasia (difficulty swallowing) following unspecified cerebrovascular disease, type 2 diabetes mellitus, bacteremia, acute kidney failure, metabolic encephalopathy, abnormality of albumin, contracture of muscle, dysarthria and anarthria, multiple sclerosis, atherosclerotic heart disease of native coronary artery without angina pectoris, and convulsions. Record review of Resident #2's quarterly MDS dated [DATE] revealed his BIMS was scored 00 indicating he was severely impaired. Record review of physician's order for Resident #2 dated 2/26/23 revealed an order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube two times a day for Pain. On 8/14/2020 Docusate Sodium Liquid 50 MG/5MLGive 5 ml via G-Tube two times a day for Constipation. Record review of Resident #2's MAR on 03/01/23 at 8:00 AM revealed Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube two times a day for Pain. On 8/14/2020 Docusate Sodium Liquid 50 MG/5ML, Give 5 ml via G-Tube two times a day for Constipation. Observation on 3/1/2023 at 8:30 AM of medications administered via G Tube by ADON, LVN, to Resident #2. She placed Acetaminophen 500 mg 2 tabs in a pouch, crushed and dissolved in water, then poured Docusate liquid 7.5 cc in medication cup and administered all medications via Resident #2's G Tube. Interview with ADON, LVN on 3/1/23 at 12:33 PM regarding medication not given via G Tube as ordered by the physician, ADON, LVN stated I was trying to do it fast and she thought she saw Acetaminophen 500 mg on the MAR Screen and she was working too fast. Interview with the DON on 03/01/23 at 1:44 PM, she said her expectation was for the staff to make sure they administered the medications according to the orders and followed physician orders. The DON stated MA A should be following the 5 rights of medication administration. Interview with the Administrator on 03/01/23 at 2:10 PM, he said he expects the nurses to give medication as ordered by the doctor. Record review of the facility's policy for Administrating Oral Medications (revised date October 2003) revealed in part . Steps in the Procedure . 4. Check the medication dose. Re-check to confirm the proper dose . Record review of the facility's Pharmacy Services/Procedures/Pharmacist/Records dated 11/28/17 read in part, . Objective: to provide the appropriate pharmacy services and safe and effective medication use for each resident admitted to the facility . Policy: . The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's physical, mental and psychosocial needs for 1 of 6 residents (Resident #9) reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan to address Resident #9's use of indwelling catheter. This deficient practice could place residents at risk of being inappropriately provided care. Findings include: Record review of Resident #9's face sheet, dated 04/19/2018, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included: cerebrovascular disease (stroke), muscle weakness (generalized), assistance with personal care, behavioral disturbance, psychotic disturbance, mood, gastrostomy status, hematuria and obstructive and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney) and aphasia. Record review of Resident 9's MDS (quarterly), dated 01/26/2023, revealed the resident's BIMS score was 11 out of 15, which indicated the resident had moderately impaired cognition, and did not address indwelling catheter, (section H - bladder and bowel and was always incontinent). Record review of Resident # 9 eMAR-Administration Note, dated 02/18/2023 and 03/01/2023, revealed Foley catheter care every shift. Record review of Resident #9 hospital discharge instructions on 1/15/23 read in part . You have been discharged with an indwelling urinary catheter . Record review of Resident #9 physician's order on 2/18/23 revealed Order Summary: Foley catheter care every shift .Change Foley Catheter using 16 fr 10ml bulb as needed . Record review of Resident #9's Care Plan dated 04/20/2018 and target date for goals 03/15/2023 revealed resident was incontinent of both bowel and bladder. Read in part . Resident will be clean, dry, odor free and will be from sign and symptom of urinary tract infection through next review . There was no care plan to address the resident's catheter. Observation on 02/28/23 on 8:00 a.m. and throughout the survey, Resident #9 was lying in bed with indwelling catheter with yellow urine in bed side drainage bag. Interview on 03/02/2023 at 10:03 a.m., Resident #9 stated He had indwelling catheter when he came back from the hospital. Interview on 03/02/2023 at 10:45 AM with MDS Coordinator, she checked current Care plan and stated I drop the ball and I forgot to care plan for the F/C. I will care plan it now. Interview on 03/02/2023 at 11:36 a.m., the DON stated she believed the facility would care plan for use of indwelling catheter and it was the MDS coordinators responsibility for completing the care plans. Interview on 03/02/2023 at 1:41 p.m., with the MDS coordinator who reviewed the care plan and said she should have care planned Resident #9's F/C. However, he was not able to find the care plan for catheter care in Resident #9s EMR. The MDS coordinator further said the reason for care planning F/C was to ensure interventions were effective and she was ultimately responsible for the care plan. Record review of the facility's Nursing Policy and Procedure Manual policy , titled Comprehensive Care Planning, read in part . The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs Each resident will have a person-centered care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .

Based on interview and record review, the facility failed to ensure a person was designated as the infection preventionist had completed specialized training in infection prevention and control for the facility in that: -The facility Infection Control Nurse was not certified. -The facility Infection Control Nurse was not experienced in infection control and did not have the knowledge to perform the role. This failure could have placed the residents at risk for infectious outbreaks as the Infection Preventionist did not have the knowledge necessary to prevent infections from occurring. Findings included: On 3/1/2023 at 1:56 pm the Surveyor presented the ADON who was the designated infection control nurse with a copy of the facility's Antimicrobial Stewardship which contained the protocols for Urinary Tract Infections, Suspected Skin and Soft Tissue Infection, Suspected Lower Respiratory Tract Infection and Fever with Unknown Focus of Infection. The ADON said she did not recognize the protocols nor the facility Antimicrobial Stewardship. Interview with the ADON on 3/1/2023 at 1:57pm, she said she had been doing Infection Control since December. She said the CDC has 20 modules to get certified. About 20 hours. She said she was taking the course and was about halfway through the course. Interview with the DON on 3/1/2023 at 14:00 she said the ADON was doing infection control and it was discussed in the mornings when they had new antibiotics. She said they have hired some new people and were waiting for onboarding as corporate would like for them to be doing their duties. She said they would prefer them doing just their jobs as DON and ADON. She said the expectation for the ADON position was infection control, staffing, monitoring documentation, and perform in-serviced. Interview on with the Administrator on 3/1/2023 at 2:11pm, she said the job responsibilities of the ADON were, infection control and assistant for the DON. She said she was also support for the charge nurses, so they report to her. Interview with the Administrator on 3/2/2023 at 08:52am, she said when someone who takes the role as infection control nurse and was not certified you can have an outbreak and have a very bad outcome with infections with the residents. Interview with the Regional Nurse on 3/2/2023 at 09:10am, he said if an infection control nurse was not certified they could have an outbreak of infections at the facility and this can have an adverse effect on the residents. Record review of the facility's job description titled, Assistant Director of Nursing, dated 2014, read in part . participation in Infection Control. Record review of the facility's infection control policy titled, Antimicrobial Stewardship, dated 2019, read in part licensed nursing staff will receive training related to antibiotic stewardship, the facilities criteria for initiating antibiotics .this training will occur as part of the nurses orientation. Record review of the facility's infection control plan titled, Infection Control Plan: Overview, dated 2019, read in part The facility will establish and maintain an Infection Control Program designed to .help prevent the development and transmission of disease and infection

Based on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #6) reviewed for significant medication errors. -The facility failed to ensure that Resident #6's blood pressure medications were administered as ordered by his physician. This failure could affect all residents who received blood pressure medications placing them at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: Record review of Resident #6 's admission face sheet dated 03/01/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified atrial fibrillation, spondylolisthesis, lumbar region, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, paranoid schizophrenia dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Record review of Resident #6's quarterly MDS dated [DATE] revealed his BIMS was 14 out of 15 indicating she was cognitively intact. The resident required extensive assistance of one staff for bed mobility, transfers, and personal hygiene. She was always incontinent of bladder and bowel. Record review of Resident #6's consolidated physician's orders dated 12/20/2021, revealed orders for the following medication: -Cardizem Tablet 60 MG (Diltiazem HCl) Give 1 tablet by mouth two times a day, related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE if SBP less than 100 DBP less than 60 or HR (heart rate) less than 60 hold and call M.D. if SBP (Systolic BP = Contracture of the heart) greater than 160, DBP (diastolic BP = heart relaxation) greater than 110 or HR (heart rate) greater than 110 call M.D (Medical Doctor). Observation of medication administration on 3/1/23 at 7:58 AM revealed MA B took Resident #6's blood pressure (BP was 144/106, Pulse =117). MA B punched the Cardizem Tablet 60 MG (Diltiazem HCl) 1 tablet and administered by mouth with other medication. MA B did not notify the nurse or the M.D about the pulse 117. Interview with MA B on 3/1/23 at 12:42 PM, she said she did not tell anyone about the increased pulse . She said she would be letting the nurse know. MA B said she did not know the consequences of high heart rate and she had medication in-services about one year ago, not recent. Interview on 03/01/2023 at 5:30 p.m. the DON stated she expected the nursing staff to take blood pressure before blood pressure, pulse and medications were given. She said if blood pressures and pulse were not within the range of what the physician order, that the medications should be held. She would not have given the medications but would hold the medication and report it to the her or the nurse. If the blood pressure was within normal range, she would give the medications. The DON said MAs had not had recent in-service on medication administration. She said she will have to in-service MA's and she could not remember when the last in-service was done. Interview with the Administrator on 3/2/23 at 10:30AM, she said she expects the nurses to administer medication as ordered by the doctor and follow the 5 rights of medications administration. Record review of the facility policy titled Medication Administration Procedures revised 2003, Read in part . Step 13: Administering the Medication Pass . When ordered or indicated, include specific item (s) to monitor ( e.g., blood pressure, pulse, blood sugar, weight), frequency( e.g. , weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber .

Based on observation, interview and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of two medication carts (1 medication carts ) reviewed for drug labeling and storage, in that: -Medication cart for nurses had 2 Fluticasone propionate nasal spray USP 50 mcg open and 2 Hibiclean 4% Chlorhexidine gluconate Solution open with no date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: Observation of the nurse's medication cart on [DATE] at 12:55 PM revealed there were 2 bottles of Fluticasone propionate nasal spray USP 50 mcg open with no date and 2 bottles of Hibiclean solution (used for wound cleaning) open not dated Interview with the ADON, LVN on [DATE] at 1:10 PM, she said she was not sure when the 2 Fluticasone propionate nasal spray USP 50 mcg and Hibiclean solution was open and she was going to find out when the medication was open. She said she was not sure how often she was supposed to check the medication cart and was not sure when was the last time she had medication training on labeling was done. Interview with the DON on [DATE] at 3:09 PM, she said the nurses were responsible for dating medications when open for expired medication. The DON said she will be checking the medication cart and do a lot of in-services. Record review of the facility's policy titled recommended medication Storage (Revised ,d+[DATE]) revealed in part . Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened .